UNIVERSITY  OF  CALIFORNIA 
AT   LOS  ANGELES 


313     1 


THORACIC  DISEASES: 

THEIU     PATHOLOGY,    DIAGNOSIS 
AND     TREATMENT. 


BY  CALVIN  NEWTON,  A.  M.,  M.  D., 

Fellow  of  the  Massachusetts  Medical  Society ; — Professor  of  General  and  Special  Pathology  in 

the  Worcester  Medical  Institution  ; — also  in  the  Syracuse  Medical  College:— and 

late  Professor  of  Rhetoric  and  Hebrew  in  Waterville  College. 

A  N  D    B  Y 

MARSHALL  CALKINS,  A.  B.,  M.  D., 

Professor  of  Anatomy  and  Physiology  in  the  Eclectic  Medical  College  of  Pennsylvania. 


WITH     A 

BIOGRAPHICAL    SKETCH 

OF     THE 


WORCESTER: 

PUBLISHED  BY  D.  AND  M.  CALKINS. 
1854. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1854, 

BY  MARSHALL  CALKINS,  M.  D., 
In  the  Clerk's  Office  of  the  District  Court  of  Massachusetts. 


PRINTED  BY  HENRY  J.  HOWLAND,  WORCESTER,  MASS. 


PREFACE. 

One  object  which  Dr.  Newton  had  in  the  preparation  of  this  work,  was  to  sup- 
ply the  increasing  demand  in  the  New  School  of  Medicine,  for  a  scientific  treatise 
upon  the  Pathology,  Diagnosis  and  Treatment  of  Thoracic  Diseases  ;  and  another 
was  to  make  public  the  results  of  his  own  study  and  investigation  into  General 
and  Special  Pathology,  and  the  means  of  Physical  Diagnosis.  Many  new  reme- 
dies, though  in  general  use  among  the  physicians  of  the  New  School,  yet  not  in 
common  use  by  the  whole  profession,  are  substituted  for  those  upon  which  depen- 
dence has  chiefly  been  placed  for  the  removal  of  inflammatory  diseases.  That 
they  are  much  more  efficient,  and  at  the  same  time  less  injurious  to  the  constitu- 
tion, a  thorough  trial  will  demonstrate.  During  nine  years,  Dr.  Newton  had  giv- 
en special  attention  to  the  study  of  thoracic  diseases,  and  their  treatment,  and 
hence  he  could  reasonably  claim  ample  qualification  to  execute  the  task  which  he 
commenced.  He  had  formed  the  plan  for  the  whole  work  and  had  written  all  the 
general  principles  of  pathology  and  diagnosis,  and  also,  a  particular  description  of 
several  of  the  more  important  diseases  of  the  thorax.  Dr.  Newton's  writing 
ends  on  the  two  hundred  and  twenty-sixth  page,  at  which  place  the  writing  of  the 
Completing  Author  commences.  In  the  completion  of  the  work,  the  pathology, 
diagnosis  and  prognosis,  have  been  chiefly  derived  from  the  best  medical  author- 
ities of  the  age ;  and  yet,  such  alterations  have  been  made  as  investigation  seemed 
to  suggest.  The  treatment  recommended,  is  .substantially  that  of  New  School 
Authors,  with  such  modifications  as  have  seemed  necessary,  and  of  practical  utili- 
ty. Being  a  student  of  Dr.  Newton  in  1847  and  1848,  and  having  been  since 
that  time  associated  with  him  in  the  practice  and  teaching  of  medicine  during  a 
limited  period,  good  opportunities  have  been  afforded  for  learning  his  peculiar 
views  of  the  pathology  and  treatment  of  disease.  From  many  other  medical  gen- 
tlemen of  extensive  experience  much  valuable  information  has  been  derived,  to 
whom  the  Completing  Author  would  here  express  his  thanks  for  the  interest 
which  they  have  manifested  in  the  work,  and  for  their  many  voluntary  contribu- 
tions to  the  treatment  of  disease.  In  conclusion  he  would  simply  say,  that  he 
has  used  every  possible  effort  to  make  the  work  valuable  for  the  profession,  to 
which  it  is  now  offered,  with  the  hope  that  it  may  be  the  means  of  alleviating  hu- 
man suffering,  and  of  the  advancement  of  sound  medical  education. 

Worcester,  July  1854. 


.3.19731 


CONTENTS.' 


THORACIC  DISEASES,  17 
PART  I.    General  Considerations,  18 
DIVISION  I.     Pathology,  18 

CHAP.  I.     Fever,  discussion  of  its  nature,  19 

"  II.     Inflammation,  theories  of;  its  nature ;  author's  views,  20 — 34 

"  III.     Congestion,  active  and  passive,  34 — 35 

"  ,IV.     Serous  Effusion,  pathology  of,  35 

"  V.     The  Reparative  Process  ;  discussion  of  its  nature,  37 — 45 

"  VI.     The  Red  Corpuscles ;  description  of,  45 — 50 

"  VII.     The  Formation  of  Pus  ;  its  kinds,  chemical  and  microscopic  char- 
acter, 50 — 55 

"  VIII.     Ulccration,  55 

"  IX.     Mortification  ;  sphacelus,  gangrene,  57 

"  X.     Lymphatic  Swellings,  58 

"  XI.     Tubercles :  their  pathology  and  microscopic  character,  59 — 69 

"  XII.     Carcinoma ;  forms  of;  chemical  and  microscopic  character,  69 — 77 

"  XIII.     Melanosis  ;  various  forms  of,  77 — 80 

"  XIV.     Xon  Malignant  Tumors,  encysted,  hydatids,  vascular,  80 — 82 

DIVISION  II.     Diagnosis :  definition,  83 

CHAP.  I.     Symptoms  ;  divisions  of,  rational,  constitutional,  physical  signs,  83-85 
"       II.     Topographical  terms  ;  regions  of  thorax  and  abdomen,  85 — 87 
"       III.     Position  of  patient  for  physical  exploration,  87 
"       IV.     Succussion ;  Hippocratic,  89 
"       V.     Palpation,  89 
"       VI.     Inspection,  90 
"      VII.     Mensuration,  91 

"       VIII.     Percussion;    sounds  of ;  cracked  pot  sound;  mediate  and  imme- 
diate, 91—92 

Pleximeters  ;  directions  for  their  use,  93 — 95 
"     Its  range  of  application  and  utility,  96 
"       IX.     Auscultation,  97 

Sec.  I.     Mode  of  application,  mediate  and  immediate,  97 

Stethoscopes;  kinds  of;  manner  of  using,  98 — 103 
Sec.  II.     Healthy  sounds  of  respiration  ;  (a)  tubular  ;  (b)  vesicular, 

103—108 

Varieties  of  healthy  sound,  108 

Sec.  III.     Diseased  sounds  of  respiration  ;  (a)  bronchial ;  (b)  cavern- 
ous;  (c)  amphoric,  110 — 112 
Varieties  of  diseased  sounds,  115 
Sec.  IV.     Rales;  the  dry,  116—120 
"        humid,  120—124 
"    V.     Adventitious  Sounds,  124 

"    VI.     Sounds  of  the  Voice,  bronchophony,  *  pectoriloquy,  ego- 
phony,  126—129 


CONTENTS.  V 

CHAP.  X.    Rational  Symptoms,  129 

Sec.  I.     Dyspnoea  ;  causes  of;  table  of  causes,  129 — 132 
"    II.     Cough ;  varieties  of,  132—135 
"    III.     The  Sputa ;  varieties  of,  135—138 

DIVISION  III.     General  Treatment,  139—142 

PART  II.     Particular  Diseases,  143 
DIVISION  I. 

CHAP.  I.     Bronchitis, 

Sec.  I.     Pathology,  143 

Diagnosis ;  general  and  special  symptoms,  145 
Prognosis  and  Treatment,  148 
"    II.     Secondary  Acute  Bronchitis,  149 
"    III.     Chronic   Bronchitis,  Pathology,   Diagnosis,    Treatment, 

150—154 

"    IV.     Bronchitis  of  Children  ;  Treatment,  155 
"    V.     Epidemic  Bronchitis  or  Influenza,  156 
"    VI.     Bronchitis  of  Old  People ;    Diagnosis  and  Treatment, 

157 — 158 

"    VII.     General  Itemarks  on  Bronchitis,  158 
"       II.     Pertussis;  Pathology,  160 

Diagnosis  ;  general  and  special  symptoms,  161 — 162 
Prognosis  and  Treatment,  163 — 165 
"       III.     Asthma;  Pathology,  165 

Diagnosis,  168—169 
Prognosis  and  Treatment,  171 — 173 
"       IV.     Morbid  Changes  in  the  Bronchi, 
Pathology,   173 
Diagnosis,  175 

Prognosis  and  Treatment,  176 
"       V.     Pneumonitis, 

SEC.  I.     Pathology,  177 
Diagnosis,  183  , 
Prognosis,  189 
Treatment,  190 
"     II.    Asthenic  Pneumonitis :  Treatment,  192 — 193 

Bilious  and  Typhoid,  194 
*'     III.     Lobular  Pneumonitis, 
Pathology,  195 
Diagnosis,  196 
Prognosis,  197 
Treatment,  198 

"     IV.     Secondary  Pneumonitis,  198 
"       VI.     Pulmonary  Emphysema,  199 

SEC.  I.     Vesicular  Emphysema,  200 
Pathology,  200 
Diagnosis,  203 

Prognosis  and  Treatment,  205 
"     II.     Interlobular  Emphysema, 
Pathology,  206 

Diagnosis  ;  Prognosis  ;  Treatment,  207 
"       VII.     Pulmonary  Congestion, 
Pathology,  208 
Diagnosis;  Treatment,  209 


VI  CONTENTS. 

CHAP.  VIII.     Pulmonary  Apoplexy,  21 1 
Pathology,-  212' 
Diagnosis,  214 
Prognosis ;  Treatment,  215 
"       IX.     Pulmonary  Gangrene, 
Pathology,  216 
Diagnosis,  217 
Prognosis ;  Treatment,  219 
"       X.     Pulmonary  Oedema, 
Pathology,  220 
Diagnosis,  221 
Prognosis;  Treatment,  222 
"       XI.     Pleuritis^  222 

SEC.  I.     Primary  Sthenic  Pleuritis, 
Pathology,  223 
Diagnosis,  230 
Prognosis,   237 
Treatment,  238 

"     II.     Asthenic  Pleuritis,  244 
"     III.     Chronic  Pleuritis,  244 
Pathology,  245 
Diagnosis",  246 
Prognosis,  247 
Treatment,  248 

Paracentesis  Thoracis,  249 — 252 
Description  of  Operation,  253 — 257 
Treatment  to  prevent  its  necessity,  257 — 259 
"     IV.     Latent  Pleuritis,  259—260 
"     V.     Secondary  and  Complicated  Pleuritis,  261—263 
"    VI.     Pleuritis  of  Children,  264—265 
"       XII.     Pneumothorax, 

Pathology,  265 
Diagnosis,  266 
Prognosis,  269 
Treatment,  270 
"  XIII.  Hydrothorax, 

Pathology,  272 
Diagnosis,  273 
Prognosis,  274 
Treatment,  275 
"  XIV.  Empyema, 

'  Diagnosis,  280 

Prognosis;  Treatment,  281 
"      Pulsating;  Treatment,  282—283 
"       XV.     Phthisis ;  definition  of,  283 

SEC.  I.     Tubercles  ;  History  of  their  pathology,  284 

Pathological  characters ;  causes  of,  286 — 289 
Location ;  law  of  their  deposition,  290 — 292 
Forms  of;  Progress  of;  Softening  of,  293 — 295 
Effects  upon  the   lungs  ;    Cavities ;   Adhesions, 

296—299 

"     II.     General  course  of  Phthisis,  and  General  Symptoms,  300 
Tuberculous  Cachexia,  301 
Stages  of  Phthisis,  301 

(a)  first  stage ;  Diagnosis,   General  and  Special 

Symptoms,  301—305 

(b)  second  stage ;  Diagnosis,  General  and  Spec- 

cial  Symptoms,  305—308 


CONTENTS.  Vll 

(c)  third  stage  ;  Diagnosis,  General  and  Special 

Symptoms,  308—311 

Particular  consideration  of  Rational  Symptoms,  311 
Cough ;    Expectoration ;    Dyspnoea  ;    Haemoptysis  ; 

Pain,  311-318 

Constitutional   Symptoms  ;    Fever  ;    Night  Sweats  ; 
Emaciation  ;  Diarrhoea,  319 — 321 
(Edema :  Cerebral,  Digestive  and  Sexual  Symp- 
toms, 321-324 
Duration  of  Phthisis,  324 
'SEC.  III.     Varieties. 

Acute  Phthisis,  324 
Chronic     "          326 
Phthisis  of  Children,  327 
Latent  Phthisis,  329 
SEC.  IV.  '  Complications,  331 

With  Ulceration  of  air-passages,  332 
"     Disease  of  Pleura,  333 
"     Abdominal  Diseases,  333 
"     Disease  of  Liver,  334 
"     Fistula  in  Ano,  335 
Differential  Diagnosis,  335-338 
SEC.  V.     Causes  of  Phthisis  : 

Hereditary  Predisposition;  339 

Influence  of  Age  ;  Occupation ;  Climate,  341-345 

"       of  Mahria:  Inflammation:  Contagion,  345-346 
"       "    Intemperance  Dyspepsia,  347-348 
"       "    Masturbation:  Poisonous  Medicine,  349 
Prognosis,  350 
SEC.  VI.  Treatment,  351 

(a)  Preventive  and  Curative,  351-363 

(b)  Palliative,  363-368 
CHAP.  XVI.     Pulmonary  Cancer  :  3(51) 

Of  Mediastinum,  371 

DIVISION  II.     Diseases  of  the  Heart,  373 

Their  History :  General  Diagnosis  and  Prognosis,  373-377 
CnAP.  I.     Examination  of  the  Heart. 

Position :  Size :  Impulsion,  377-381 
Physical  Signs,  382-384 

Normal  Sounds  :  Ithythm,  384-386 
Abnormal  Sounds,  387 

Pericardial     "      the  Friction,  Creaking  Leather,  the  Churn- 
ing Sound,  392 
Irregularities  of  Rhythm,  393 
Vascular  Sounds,  bruit  de  diable,  393 
CHAP.  II.     SEC.  I.     Pericarditis. 

Pathology,  394 
Diagnosis,  395 
Prognosis,  398 
Treatment,  401 
SEC.  II.  Chronic  Pericarditis. 
Diagnosis,  399 
Prognosis,  400 
Treatment,  401 


Vlll  CONTENTS. 

CHAP.  III.    Endocarditis,  405 

Pathology,  406 
Diagnosis,  408 
Prognosis,  110 
Treatment,  411 
CHAP.  IV.  Myocarditis,  413 

Pathology,  413 
Diagnosis,  414 
CHAP.  V.     Hypertrophy,  414 

Pathology,  416 
Diagnosis,  416 

Prognosis :  General  Treatment,  418 
Treatment  of  Hypertrophy,  421 
CHAP.  VI.    Dilatation  of  the  Heart,  424 
Pathology,  425 

Diagnosis:  Prognosis:  Treatment,  426 

CHAP.  VH.     Disease  of  the  Valves  of  the  Heart,  427 

Pathology,  427 

Diagnosis,  428 

Treatment,  430 

Varieties  of  Organic  Disease,  431 
Atrophy:  Softening,   431 
Fatty  Degeneration  :  Tubercles,  Hydatids,  432 
CHAP.  VHI.     Hydropericardium,  433 

CHAP.  IX.    Functional  Disease  of  the  Heart :  Palpitation,  433 
Pain:  Intermittence,  434 
Angina  Pectoris,  434 
Treatment,  435 

DIVISION  HI.    Aortic  Diseases,  435 

CHAP.  I.    Aortitis:  Pathology,  435 

Diagnosis :  Treatment,  436 
CHAP.  H.     Aneurism  of  the  Aorta. 
Pathology,  436 
Diagnosis,  437 

Prognosis  and  Treatment,  438 
Appendix  of  Formulae,  440 


BIOGRAPHICAL    SKETCH 


OF    THE    LIFE   AXD   CHARACTER  OF 


CALYIN    NEWTON,  M.  D. 


BIOGRAPHIES  of  medical  authors  arc  seldom  found  in  their  works.  Their 
professional  appropriations  to  the  science  of  medicine  are  their  only  public 
memorial.  Many  circumstances,  however,  'make  a  historical  sketch  of  the 
life  of  Professor  Calvin  Newton  desirable,  not  only  by  his  relatives  and  pro- 
fessional friends,  but  by  that  extensive  circle  of  acquaintance  that  he  formed 
during  the  period  of  his  collegiate  teaching,  and  clerical  labors. 

Calvin  Newton  was  born  in  Southborough,  Mass.,  on  the  26th  of  No- 
vember 1800,  His  father,  Mr.  Josiah  Newton,  was  a  respectable  farmer 
and  revolutionary  soldier  who  held  many  town  offices,  and  the  deaconship 
of  the  Congregational  Church  in  his  native  parish.  His  mother,  Mrs.  Eliz- 
abeth Haynes  Newton,  a  lady  of  benevolence  and  piety,  still  lives  in  Ash- 
land. His  origin  was  from  a  family  remarkable  for  longevity  and  character- 
ized by  a  full  mental  and  physical  development. 

In  early  life  he  manifested  superior  powers  of  mind.  At  the  age  of  eight 
years  he  commenced  the  study  of  English  Grammar,  under  the  instruction  of 
his  older  brother,  llev.  Gideon  J.  Newton,  who  says,  "he  easily  comprehended 
the  ideas  of  authors,  so  that  lie  soon  was  prepared  to  enter  the  first  class  of 
Grammarians."  In  the  science  of  numbers,  he  had  few  successful  compet- 
itors ;  in  every  study  he  was  thorough,  deducing  the  general  from  the  partic- 
ular, and  easily  recognizing  the  relations  of  the  various  branches  of  knowl- 
edge. Possessing  the  "  high  purpose,"  "  the  firm  resolve,"  and  "  the  clear 
conception," — the  elements  of  success  in  literary  pursuits, — he  improved 
every  opportunity  for  mental  culture,  the  school  vacation,  the  winter's  eve- 
b 


X  BIOGRAPHICAL    SKETCH. 

ning,  the  summer's  morning.  While  others  sported,  he  studied,  while  oth- 
ers slept  the  sleep  of  the  sluggard,  he  sought  the  society  of  those  golden 
records  written  by  the  genius  of  every  country  and  of  every  age.  To  receive 
instruction  was  his  pleasure,  to  impart  it,  his  delight.  A  youth  of  sixteen 
he  commenced  teaching  in  a  village  school,  and  soon  after  the  study  of  the 
classics  with  the  clergyman  of  his  native  parish.  At  Framingham  Academy, 
he  completed  his  preparation  for  college. 

In  1820,  he  entered  Brown  University,  where  he  remained  nearly  two 
years,  until  the  death  of  his  father  deprived  him  of  the  means  with  which  to 
complete  his  collegiate  course.  The  sudden  removal  of  that  dear  object  of 
filial  affection  made  a  deep  and  lasting  impression  on  his  mind.  Reflection 
followed  and  that  most  desirable  of  all  moral  changes,  the  honest  and  sin- 
cere consecration  of  his  talents  and  acquirements  to  the  service  of  God.  In- 
timately connected  with  these  events  of  his  life,  is  another,  deserving  a  pass- 
ing notice.  Of  this  I  have  often  heard  him  speak  with  the  simplicity  of  a 
child,  while  the  tear  of  grateful  remembrance  told  the  deep  emotions  of  his 
soul.  "  I  can  never  speak  "  says  he,  "  of  the  benevolent  act  of  Col.  Dex- 
ter Fay,  of  Hon.  Francis  B.  Fay,  and  of  Hon.  Sullivan  Fay,  in  lending  me 
the  means  with  which  to  complete  my  collegiate  course,  without  yielding  up 
reason  to  the  guidance  of  feeling." 

Freed  from  pecuniary  embarrassment,  he  returned  to  Brown  University, 
and  there  completed  his  junior  year.  Subsequently  he  went  to  Union 
College,  where  he  received  the  degree  of  Bachelor  of  Arts  in  the  year  1826, 
and  afterward  that  of  Master  of  Arts  in  the  year  1829.  During  his  senior 
year,  he  taught  a  high  school  in  Worcester,  and  at  the  same  time  pursued 
his  collegiate  studies.  The  means  thus  acquired  being  sufficient  in  amount, 
were  immediately  used  for  the  payment  of  his  borrowed  money.  While  en- 
gaged in  teaching,  he  was  convinced  that  duty  called  him  to  the  work  .of  the 
Christian  ministry.  Previously  a  member  of  a  church  in  Providence,  he 
then  united  with  the  Baptist  Church  in  Southborough,  from  which  he  re- 
ceived a.  license  to  enter  upon  the  duties  of  the  clerical  profession.  In  1826 
he  commenced  the  study  of  Divinity  in  Xewton  Theological  Seminary,  and 
in  1829,  received  the  highest  honors  of  that  Institution.  During  the  pur- 
suit of  his  theological  studies,  he  frequently  preached  in  the  Baptist  Church 
at  Bellingham,  and  in  1828,  October  22nd,  he  was  ordained  its  Pastor. 


BIOGUAPIIICAL    SKETCH.  XI 

While  at  Framing-ham  Academy,  he  had  formed  an  acquaintance  with 
Miss  Millisent  Johnson,  an  intellectual  and  religious  lady.  About  the  time 
of  his  settlement  in  Bellingham,  they  were  married.  To  him  she  ever  proved 
a  devoted  and  faithful  companion,  and  although  he,  on  account  of  her  ill- 
health  during  the  latter  years  of  his  life,  expected  to  follow  her  to  the  tomb, 
yet  she  suddenly  deprived  of  the  object  of  her  affection,  still  lingers  on  the 
verge  of  the  grave. 

In  1832  he  was  elected  to  the  Professorship  of  Rhetoric  and  Hebrew  in 
Waterville  College.  After  remaining  there  five  years,  he  was  elected  Pres- 
ident and  one  of  the  Professors  in  the  Theological  Institution,  first  estab- 
lished at  Charleston  Me.,  but  afterward  removed  to  Thomaston. 

He  was  connected  with  this  Institution  four  years.  Subsequently  he  be- 
came the  Pastor  of  the  Baptist  Church  in  Grafton,  Mass.,  where  he  remained 
about  three  years,  until  declining  health  induced  him  to  change  his  pro- 
fession. 

In  early  boyhood  he  manifested  interest  in  the  science  and  practice  of 
medicine  ;  and  although  later  in  life,  his  moral  sense  pointed  out  another 
path  of  duty,  yet  he  perceived  the  necessity  for  a  radical  and  salutary 
change  in  the  cure  of  disease.  In  the  conservatism  of  tho  University,  he 
saw  the  bias  "of  antiquity  ;  in  the  common  sense  suggestions  of  the  untutored 
mind  an  occasional  .gleam  of  truth  ;  in  the  former,  the  ornament  and  sym- 
metry of  science,  in  the  latter  the  practical  wisdom  of  unchained  genius. 
Midway  between  these  extremes  bright  and  safe  appeared  the  course  of  rea- 
son, great  and  enduring  the  improvements  to  which  it  leads.  Although  ed- 
ucated at  the  University  at  Cambridge  and  the  Berkshire  Medical  Institu- 
tion, yet  he  was  uninfluenced  by  their  conservative  spirit.  Free  from  prej- 
udice, not  biased  by  sect  or  creed,  he  sought  to  interrogate  nature  in  the 
language  of  science,  and  to  rightly  interpret  every  phenomena  which  she 
presents.  After  the  manner  of  inductive  philosophy  he  sought  to  deduce  from 
facts  some  general  principle,  to  guide  the  physician  in  the  cure  of  disease. 

After  graduating  at  the  Berkshire  Medical  College,  and  his  admission  into 
the  Massachusetts  Medical  Society,  he  commenced  the  practice  of  his  pro- 
fession in  Worcester.  During  the  whole  course  of  his  medical  study,  he 
gave  special  attention  to  every  new  remedy  and  process  of  cure,  which 
promised  to  become  an  improvement.  With  interest  he  heard  of  the  dis- 


Xii  BIOGRAPHICAL    SKETCH. 

coveries  of  that  rustic  Son  of  New  Hampshire  ;  how  that  in  many  cases  his 
simple  vegetable  remedies  were  more  successful  when  prescribed  by  the 
hand  of  ignorance — than  the  common  remedies  when  prescribed  by  the 
hand  of  science.  Not  believing  in  all  his  crudities,  he,  nevertheless,  saw  in 
the  simple  process  of  applying  medicine,  and  in  the  changes  in  the  Materia 
Medica  suggested  by  Thomson,  a  germ  whose  future  development,  by  the 
fostering  care  of  science  would  become  to  the  world  an  inestimable  blessing. 

Opportunities  for  the  administration  of  the  new  remedies  were  improved, 
in  order  to  test  their  efficacy,  and  ascertain  the  extent  of  their  healing  power. 
Confidence  followed  experiment,  and  a  firm  determination  to  place  their  util- 
ity in  a  conspicuous  position  before  the  world,  succeeded  the  conviction  of 
reason.  Following  the  example  of  Galen,  he  sought  to  combine  the  practi- 
cal wisdom  of  Hippocrates  and  the  rigid  logic  of  Aristotle,  and  also,  to  add 
to  their  attainments  the  treasures  of  modern  discovery  and  invention.  He 
had  no  blind  reverence  for  the  authority  of  names.  "  Hereafter,"  he  re- 
marks, in  an  address  to  his  classmates  of  the  Berkshire  Medical  Institution, 
"  it  will  not  be  sufficient  to  refer  to  authority  in  support  of  a  particular 
practice.  In  the  eye  of  the  discerning,  it  matters  not,  whether  error  is  old, 
and  has  the  sanction  of  distinguished  names,  or  is  new  and  unauthorized. 
The  poisonous  draught  is  none  the  less  bitter  for  having  been  already  tasted 
by  numbers.  It  is  now  becoming  fashionable,  in  the  community  to  bring  every 
thing  to  the  test  of  experience.  We  must  have  the  why  and  the  wherefore 
to  sustain  any  measure  ;  and,  with  the  greatest  reluctance,  only  can  we  ad- 
mit what  is  incapable  of  proof,  to  have  science  for  its  basis.  Plain  common 
sense  comprehending  in  a  measure  the  nature  of  disease,  and  proving  by  ob- 
servation and  experience  what  medicines  will  do,  is  it  not  to  be  put  aside  by 
any  reference  to  the  history  of  remedies,  and  what  has  been  thought  in 
times  past  to  be  their  action.  Many,  however,  have  even  up  to  the 
present  time,  seemed  to  suppose  that  the  authority  of  names  was  all  the 
support  their  practice  required ;  and  with  them  a  reference  to  Cullcn  or 
Brown,  or  other  distinguished  individuals,  is  of  more  importance  than  an 
overwhelming  host  of  facts.  With  such  persons,  in  truth,  all  investigation 
is  proscribed ;  whereas  we  are  beginning  to  learn,  that  to  the  test  of  close 
scrutiny  everything  claiming  to  be  science  must  be  brought." 

With  such  liberal  views  of  medicine,  he  entered  upon  its  practical  duties 


BIOGRAPHICAL    SKETCH.  Xlll 

Around  him  on  the  one  hand  were  the  representations  of  Allopathy,  on  the 
other  a  few  pioneers  of  medical  reform.  To  the  progressive  party,  he 
mainly  looked  for  sympathy  and  support,  into  its  ranks  he  proposed  to  intro- 
duce the  benefits  of  scientific  study.  Himself  the  recipient  of  thorough 
literary  culture  and  medical  education,  he  knew  their  utility,  and  realized  the 
benefit  that  their  possession  confers.  Than  himself,  in  these  respects,  none 
were  better  qualified  to  lead  minds,  but  imperfectly  educated  up  to  higher 
stations  of  medical  attainment.  Why  was  medical  reform  generally  unap- 
provcd  by  the  literati,  and  aristocracy  of  New  England  ?  Why  had  its  ad- 
herents such  an  amount  of  prejudice,  such  bitter  opposition  to  overcome  ? 
One  reason,  doubtless  was,  the  tendency  of  the  human  mind  to  condemn 
the  new,  especially  when  its  origin  is  humble  ;  another,  the  manner  in 
which  reform  was  advocated.  With  it  were  associated  the  ideas  that  every 
man  can  be  his  own  physician,  that  one  course  of  treatment  is  adapted  to 
every  form  of  disease,  that  "  heat  is  life,  and  cold  is  death." 

To  successfully  bring  to  the  notice  of  the  profession  a  new  remedy  or  new 
course  of  treatment,  requires  its  presentation  through  a  certain  channel  of 
influence.  Had  the  simple  remedies  of  Thomson  and  those  of  other  early 
reformers,  and  their  simple  course  of  medication  unconnected  with  other 
tilings  obnoxious  to  the  general  sentiment  of  mankind,  been  used  and  rec- 
ommended, in  some  of  those  foci  of  influence  which  glow  high  up  the  hill- 
side of  science,  long  since  their  merits  would  have  been  disclosed,  and  their 
benefits  have  brought  joy  to  the  afflicted  in  all  the  city  streets.  The  truth 
of  this,  Dr.  Xewton  fully  perceived.  The  remedies  were  good,  a  great  im- 
provement upon  those  in  general  use,  but  the  fact  must  be  told  from  portals 
of  science,  in  order  to  quickly  influence  the  world.  He,  therefore,  resolved 
to  free  if  possible,  the  reform  part  of  the  profession  from  their  ignorance,  to 
divest  it  of  the  forms  of  charlatanism,  which  to  some  extent  it  had  assumed, 
and  thus  to  place  it  on  a  basis  fixed  and  immovable  as  the  rock  of  scientific 
truth.  What  more  useful  enterprise,  what  nobler  object  could  occupy  the 
attention  and  kindle  the  zeal  of  a  liberal  and  educated  mind  ?  To  effect 
sucli  a  result,  to  his  mind  two  things  seemed  necessary  : — A  Medical  Institu- 
tion, and  Medical  Journal,  both  conducted  scientifically,  yet  advocating  all 
the  improvements  that  discovery  might  suggest. 

Accordingly  on  the  first  of  January  1846,  he  commenced  the  publication 


XIV  BIOGRAPHICAL    SKETCH. 

of  the  New  England  Medical  Eclectic  and  Guide  to  Health.  Portions  of 
his  editorial  address  contain  the  best  exposition  of  his  objects  and  prin- 
ciples : — 

"  Many  palhies  and  isms  in  medicine  are  prevalent  at  the  present  day 
Besides  allopathy  or  the  old  practice,  we  have  homeopathy,  hydropathy, 
Beachism,  Thomsonism,  fyc. ;  and  those  who  are  solicited  to  be  our  readers, 
will  wish  to  know,  as  we  suppose,  under  what  colors  we  intend  to  sail.  In 
answer  to  the  inquiry,  then,  we  say,  Our  flag  is  our  own.  Our  object  is  the 
•extension  of  medical  truth.  We  are  pledged  to  sustain  no  class  of  physi- 
cians or  mode  of  practice,  except  such  as  we  are  directed  to  by  reason,  sci- 
ence, and  common  sense.  We  belong,  indeed,  to  the  Massachusetts  Medi- 
cal Society,  and  are  in  fellowship  with  our  medical  brethren  ;  but  we,  like 
them,  are  at  liberty  to  use  such  remedies  in  the  removal  of  disease  as  we 
judge  to  be  the  most  efficacious.  We  are  inflexibly  opposed  to  every  form 
of  quackery ;  but  we  do  not  believe  that  medicine,  unlike  all  other  sciences 
and  professions,  is  incapable  of  improvement.  We  believe  that  much  yet 
remains  to  be  done  in  developing  the  principles  and  carrying  out  the  prac- 
tice of  the  healing  art ;  and,  if  we  can  get  at  truth,  we  care  not  from  what 
quarter  it  springs.  We  shall  never  hesitate  to  adopt  any  Indian  remedy  or 
old  woman's  prescription,  when, — its  nature  and  modus  opcrandi  being 
shown, — we  have  the  evidence,  that  its  good  effects  must  be  superior  to 
those  of  any  article  now  officinal.  Time  has  been  when  some  good  thing 
came  out  of  Xazareth ;  and  we  believe  it  eminently  true  in  medicine  that 
valuable  improvements  have  arisen  from  obscure  sources.  In  vain,  there- 
fore, do  those  who  have  enjoyed  superior  professional  advantages,  say,  "We 
are  the  people,  and  wisdom  shall  die  with  us."  Those  who  stand  at  a  dis- 
tance in  the  outer  court  of  science,  are  sometimes  as  genuine  and  acceptable, 
if  not  as  exalted  worshiped,  as  others  who  are  permitted  to  enter  the  inmost 
temple  ;  and  we  shall  try,  according  to  our  motto,  to ' 
"  Seize  upon  truth,  wherever  found, 
On  Christian  or  on  Heathen  ground." 

"It  maybe  objected,  that  the  tendency  of  on;1  Periodical  will  be  to  spread 
oat  medical  information  too  broadcast  ov-r  the  community.  To  this  we 
reply,  wa  have  no  wish  for  the  matter?  of  our  profession  to  be  kept,  like  the 
mysteries  of  Egyptian  priests,  secluded  from  all  but  the  initiated.  We  do 


BIOGRAPHICAL    SKETCH.  XV 

not,  indeed,  accord  with  Samuel  Thomson  in  the  belief,  that  every  man  can, 
with  propriety,  be  his  own  physician,  any  more  than  we  believe,  that  every 
farmer  can,  with  advantage,  be  his  own  carpenter,  or  blacksmith,  or  watch- 
maker. Every  man,  it  is  true,  can,  in  a  sense,  be  all  these  for  himself ; 
but  he  will  certainly  be  a  clumsy  performer,  so  long  as  he  attempts  to  do  a 
little  of  every  thing,  and  gains  a  competent  acquaintance  with  nothing.  The 
science  on  which  the  practice  of  medicine  is  founded, — the  knowledge  of  the 
human  system,  the  nature  and  operation  of  remedies,  and  the  like,  are  mat- 
ters not  understood,  to  the  degree  requisite  for  the  physician,  without  long 
and  arduous  study.  Still  it  is  evident,  that,  to  some  extent,  these  matters 
may  be  brought  distinctly  before  the  minds  of  the  common  people,  and  made 
level  to  the  capacities  of  all ;  and  immeasurably  better  would  it  be  for  chil- 
dren and  the  various  members  of  the  family  circle  to  employ  their  leisure 
hours  in  becoming  acquainted  with  their  physical  systems,  and  with  the 
means  of  promoting  their  health,  than  in  dissipating  their  minds  and  cor- 
rupting their  morals,  with  fictitious  stories  and  wild  romances.  Our  endeav- 
or, therefore,  will  be  the  wide  dissemination  of  medical  truth  ;  and,  were  it 
possible,  we  would  gladly  be  jwofcssioitalh/,  what  one  infinitely  greater  than 
ourselves  was  morally  and  spiritually,  a  light  to  enlighten  "  every  man 
that  comcth  into  the  world." 

"  By  those  of  our  Thomsonian  friends  who  "go  the  whole  figure," — as 
the  phrase  is, — we  may  be  thought  not  sufficiently  strenuous  for  Botanic 
principles.  Some  may  even  impugn  our  motives,  and  charge  us  with  CXUDO- 

11  i/lo  O  OO 

between  different  parties  for  the  sake  of  gaining  favor  with  all.  To  such  we 
put  the  question  of  Nicodcmus  of  old.  "  Doth  our  law  judge  any  man,  be* 
fore  it  hear  him,  and  know  what  he  docth  V"  Or,  again,  we  reply  in  the 
language  of  one  of  C;osar's  procurators,  resident  at  Ccssarca,  "  It  is  not  the 
manner  of  the  Romans  to  deliver  any  man  to  die,  before  that  he  which  is 
accused  meets  the  accusers  face  to  face,  and  have  license  to  answer  for  him- 
self concerning  the  crime  laid  against  him."  If  the  Eclectic  is  not  essen- 
tially orfhodox,  even  in  the  judgment  of  the  most  radical  Botanic,  then,  anil 
not  till  then,  let  us  be  condemned  for  heresy.  If,  indeed,  any  expect  of  us 
a  constant  warfare  with  diplomatized  physicians,  they  are  destined  to  disap- 
pointment;  for  we  do  not  believe,  that,  by  that  medium,  much  medical  truth 
is,  or  can  be  communicated.  Were  we,  or  any  member  of  our  family,  dar_- 


XVI  BIOGRAPHICAL    SKETCH. 

gerously  ill,  wo  confess,  that  we  should  prize  a  plain  description  of  the  dis- 
ease, with  the  means  of  recognizing  it,  and  the  mode  of  applying  such  rem- 
edies as  would  speedily  effect  a  cure,  far  more  highly  than  even  the  most  el- 
oquent tirade  or  phillipic  against  the  errors  of  the  schools.  And,  besides, 
we  must  plead,  in  our  own  behalf,  the  peculiarity  of  our  phrenological  devel- 
opment. Our  organ  of  comlativeness  is  not  large,  and  it  is  extremely  dif- 
ficult for  us  to  be  pugnacious.  We  think  it  better  to  love  even  our  enemies; 
and  to  trust  to  the  correctness  of  the  maxim,  "  Truth  is  great,  and  will  pre- 
vail." Very  few,  at  the  present  day,  we  believe,  will  sympathize  much  with 
a  neighbor  of  ours  who  calls  himself  a  doctor,  and  who  recently  avowed  to  a 
friend,  that  "  an  educated  physician  and  an  educated  minister  are  good  for 
nothing ;  and  that,  if  we  would  have  a  good  physician  or  a  good  minister, 
we  must  take  a  man  directly  from  the  plough."  We  would  not  conceal  the 
truth,  that  we  like  to  have  physicians  and  ministers,  as  well  as  mechanics, 
merchants,  and  others,  educated  for  their  respective  employments  ;  and  we 
cannot  help  thinking,  that  the  fable  of  the  fox  that  lost  his  tail,  has  its  moral 
in  the  case  of  the  neighbor  referred  to.  True  it  is,  that  in  medicine,  as  in 
every  thing  else,  one  may  be  taught  error  ;  and,  under  erroneous  instruc- 
ions,  he  may  have  his  mind  misdirected,  and  his  judgment  perverted  ;  but, 
this  affords  no  argument  whatever  against  a  correct  education.  It  is  the 
error  inculcated,  and  not  truth,  which  works  the  evil.  The  medical  student 
has  only  to  take  the  path  marked  out  by  reason,  science,  and  common  sense  ; 
and  then,  the  farther  he  advances,  the  better  practitioner  will  he  be.  Ac- 
cording to  our  views,  empiricism, — whether  in  or  out  of  the  regular  profes. 
sion, — diplomatized  or  not, — has  its  foundation  in  ignorance  and  error.  It 
is  the  lack  of  true  professional  knowledge,  and  not  a  redundancy,  which 
makes  the  empiric,  and  sacrifices  human  life.  Our  watchword  to  every  man 
who  would  be  a  good  physician,  will  ever  be,  Onward,  onward,  in  the  path 
of  truth.  In  this  way,  and  in  this  only,  will  you  honor  your  profession,  and 
benefit  your  race.  The  time  has  come  in  which,  to  gain  the  confidence  of 
the  people,  the  medical  practitioner  must  place  himself  on  the  platform  of 
sound  professional  principles." 

Such  were  his  ideas  of  medicine,  liberal,  philosophical,  reasonable.  To 
diffuse  them  in  the  profession,  and  to  impress  them  upon  the  minds  of  stu- 
dents, he  ever  labored. 


BIOGRAPHICAL    SKETCH.  XV11 

In  the  same  year  the  inceptive  step  for  the  establishment  of  a  Medical 
College  was  taken.  At  a  Convention  of  the  friends  of  reform,  a  Board  of 

O 

Trustees  was  chosen,  and  Dr.  Newton  was  elected  Professor.  An  unsuc- 
cessful application  to  the  Legislature  for  a  charter,  made  it  necessary  for  the 
Institution,  in  order  to  grant  degrees,  to  act  under  the  protecting  aegis  of  the 
Botanico-Medical  College  of  Georgia.  At  the  end  of  the  first  course  of  lec- 
tures, debts  had  accumulated,  which  he  and  his  co-laborer  in  reform,  Dr.  J. 
A.  Andrews,  generously  paid. 

The  next  course  of  Lectures  in  1847,  commenced,  and  progressed  under 
circumstances  somewhat  more  favorable  ;  and  although  efforts  were  yearly 
made,  no  charter  was  obtained  until  the  year  1849.  Before  a  special  com- 
mittee appointed  by  the  Senate,  Dr.  Newton  presented  the  claims  of  the  Wor- 
cester School,  in  opposition  to  the  appeals  made  by  a  committee  from  the 
Massachusetts  Medical  Society,  consisting  of  Dr.  John  Ware,  Dr.  Jacob 
Bigelow  and  Dr.  Henry  G.  Clark,  in  order  to  prevent  the  legal  existence  of  the 
Worcester  Medical  Institution.  Dr.  Newton,  however,  was  successful  in  the 
accomplishment  of  his  object. 

In  1847,  the  Eclectic  took  the  name  of  the  Journal,  under  which  title  it 
was  published  until  the  time  of  his  death.  For  its  support  he  yearly  contrib- 
uted his  editorial  services,  and  even  made  pecuniary  sacrifices  to  keep  it 
in  existence. 

In  1850,  a  College  building  was  erected  by  the  friends  of  the  enterprise 
on  Union  Hill  in  the  city  of  Worcester.  For  this,  Dr.  Newton  freely  con- 
tributed. "  To  the  welfare  of  the  Institution,"  he  remarks  "  my  heart  and 
my  life,  are,  and  shall  be  unremittingly  dedicated ;  and,  when  I  go  the  way 
of  all  the  earth,  I  hope  to  leave  behind  me,  not  merely  a  pecuniary  legacy, 
that  will  supply  some  of  the  Institution's  future  wants,  but  a  richer  legacy 
of  professional  literature  and  science,  embodied  in  medical  works  and  in- 
stilled into  the  minds  of  hundreds  and  thousands  of  the  profession." 

The  Institution  from  this  time  seemed  more  prosperous.  The  sessions  of 
1852  and  1853,  were  better  attended — and  hope  seemed  more  than  ever  be- 
fore to  inspire  the  heart  of  its  founder. 

The  establishment  of  a  State   Society  was  another  object  whose   accom- 
plishment seemed  necessary  to  the  success  of  medical  reform.     For  this  pur- 
pose, Dr.   Newton,  in  1850  was  chosen  chairman  of  a  committee,  by  his 
c 


IVlll  BIOGRAPHICAL   SKETCH. 

medical  brethren  to  draft  a  constitution  for  the  Massachusetts  Physo-Medical 
Society.  Rules  and  regulations  were  established,  and  regular  meetings  held, 
at  which  addresses  were  delivered,  and  topics  of  professional  interest  dis- 
cussed. 

In  1852  he  attended  the  National  Eclectic  Medical  Association  at  Roch- 
ester, N.  Y.,  and  was  elected  its  President,  and  one  of  a  committee  to  pre- 
pare an  address  for  the  next  annual  meeting  at  Philadelphia. 

At  Rochester  he  formed,  while  attending  the  Convention,  many  pleasing 
acquaintances  with  his  medical  brethren  ;  he  won  their  respect  and  proved 
to  them  amidst  conflicting  interests  a  nucleus  of  union.  His  election  to  the 
chair  of  General  and  Special  Pathology  in  the  Syracuse  Medical  College, 
induced  him  still  more  to  labor  for  the  production  of  harmonious  action 
among  the  reformers  of  New  York. 

By  the  friends  and  students  of  the  Syracuse  Medical  College,  his  Lec- 
tures were  very  highly  approved,  and  many  expressions  of  regard  and  af- 
fection were  mingled  with  the  sadness  of  the  parting  farewell. 

A  want  of  medical  literature  was  another  incentive  exciting  to  action  the 
mind  of  Dr.  Newton.  No  works  were  extant  written  in  a  style  purely  sci- 
entific containing  the  treatment  of  reformers  adapted  to  the  pathology  of  the 
schools.  He,  therefore,  retired  from  general  practice,  also  resigned  his 
chair  at  Syracuse  and  devoted  his  time  exclusively  to  writing.  After  the 
completion  of  his  work  on  Thoracic  Diseases,  he  had  formed  the  determina- 
tion to  visit  Europe,  in  order  to  better  qualify  himself  for  the  authorship  of 
a  work  on  Theory  and  Practice.  But  the  room  of  the  student  was  not  his 
most  healthful  element.  The  bright  sunlight  of  day,  its  toil  and  strife  were 
far  less  injurious  to  his  active  and  vigorous  frame.  From  physical  exer- 
cise his  mental  drew  too  much  of  his  attention.  The  nervous  system  suf- 
fered. In  the  words  of  Prof.  Reuben,  "  The  insidious  foe  was  lurking  in 
the  very  springs  of  life,  loosing  the  delicate  affinities,  and  cutting  off  at  their 
fountains  the  streams  of  vital  force." 

In  the  private  relations  of  life,  Dr.  Newton  was  respected  and  honored. 
By  the  citizens  he  was  elected  one  of  the  Common  Council,  a  member  of 
the  Board  of  Aldermen,  and  was  Secretary  of  the  Board  of  Trustees  of  the 
Worcester  Academy.  A  full  enumeration  of  all  the  places  of  trust  which 
he  has  occupied,  and  the  little  incidents  connected  with  the  fulfilment  of  his 


BIOGRAPHICAL    SKETCH.  XIX 

official  labors,  would  be  interesting ;  but  such  is  not  my  present  purpose.  A 
brief  consideration  of  the  more  important  points  in  his  character  will  suffice. 
In  doing  this,  I  am  well  aware  of  the  difficulties  to  be  overcome,  of  the  bias 
of  friendly  acquaintance.  To  love  and  reverence  a  teacher  and  friend,  how 
pleasant !  To  analyze  his  character,  how  repugnant  to  the  warm  glow  of  af- 
fection !  And  yet  the  public  weal  demands  an  analysis  of  the  characters  of 
leading  men,  in  order  that  their  virtues  may  be  imitated,  and  their  faults 
avoided  by  those  who  succeed  them  on  the  changing  stage  of  life. 

Dr.  Newton  was  a  powerful  man  physically,  a  man  of  a  large  mould,  a 
great  body,  and  a  great  brain ;  his  frame  vigorous  and  well  proportioned, 
every  part  alive  with  active,  vital  force.  What  a  chest  was  his  !  what  large 
pulmonary  and  digestive  organs,  those  two  factors  of  physical  and  mental 
power  !  From  thence  was  derived  his  constant  impetus  to  corporeal  exertion, 
the  fuel  supplying  the  bright  flame  of  thought.  His  personal  appearance 
was  not  indicative  of  ornament,  but  of  that  physical  strength  and  mental 
energy  and  decision  which  press  right  onward  to  their  destined  purpose. 
His  intellect  was  strong  and  active. 

The  forms  of  intellectual  action  may  be  divided  into  three  modes : — the 
Reason,  Understanding  and  the  Imagination  ;  the  Reason,  dealing  with  uni- 
versal laws,  the  philosophic  power.  The  Understanding,  with  details,  the 
practical  power.  The  Imagination,  with  beauty,  the  Poet's  gift. 

Of  Reason,  Dr.  Newton  had  a  larger  share  than  of  the  other  intellectual 
endowments.  He  was  a  man  of  philosophic  ideas,  ever  seeking  to  deduce 
from  facts  a  law,  general  and  universal.  To  generalize  was  his  ambition,  to 
strike  out  like  Bacon,  some  new  and  shorter  course  to  scientific  improve- 
ment. His  power  of  comprehension  was  uncommonly  large.  And  hence, 
from  his  mind  original  ideas  proceed.  Originality  may  be  divided  into  two 
kinds  ;  originality  in  applying  in  a  novel  manner  the  knowledge  of  others, 
and  that  originality  which  brings  forth  the  new  principle,  the  new  idea. 
This  latter  is  not  so  dependent  upon  others'  thoughts;  it  has  a  creative  power 
of  its  own  ;  within  the  boundaries  of  genius  is  the  field  of  its  labor.  View- 
ing things  subjectively,  it  moulds  into  its  own  likeness  the  external  world. 
In  its  ideal  creations  are  newness,  and  freshness,  are  forms  of  utility  unseen 
by  common  minds.  Traveling  in  untrodden  paths,  pursuing  its  diverse  way 
into  the  dark  labyrinths  of  the  unknown,  there  from  a  spark  of  intellec- 


XX  BIOGRAPHICAL    SKETCH. 

tual  agency  it  kindles  the  radiant  flame  of  science.  Of  this  latter  kind  Dr. 
Newton  possessed  the  more,  of  the  former  the  less.  His  ideas  of  disease 
were  neither  those  of  Allopathy,  nor  those  of  Thomsonism  or  Bcachism ;  they 
were  peculiarly  "  his  own."  He  organized  new  associations  of  physicians, 
and  moulded  a  system  of  successful  medical  empiricism  into  the  form  of  sci- 
entific knowledge. 

His  Understanding  was  less  than  his  Reason.  Although  he  acquired 
readily  and  retained  well,  his  perception  was  less  acute  than  that  of  many 
minds  inferior  to  his  own.  In  adapting  means  to  the  accomplishment  of  an 
end,  his  large  hope  sometimes  caused  him  to  overlook  many  of  those  minor 
contingencies  which  mould  and  fashion  results. 

The  secret  of  his  success,  lies  mainly  in  his  reason,  in  his  comprehensive 
views  of  the  subjects  of  medical  study,  in  his  indomitable  perseverance,  in 
his  devotion  to  one  object,  in  his  spirit  of  self-sacrifice.  To  science  he 
seems  to  have  paid  much  attention,  more  than  to  general  history  and  liter- 
ature. 

I  cannot  claim  for  him  large  imagination.  His  eloquence  lacks  the  poetic 
charm,  the  beauty  which  makes  luminous  the  page,  and  touches  the  heart  of 
humanity.  Two  or  three  short  poems  are  all  that  his  poetic  faculty  has  left. 

One  on  Superstition,  has  the  following  excellent  lines  : — 

» 
"  Hail !  Sacred  knowledge.     Freedom's  purest  Friend, 

The  richest  boon  which  Heaven  to  earth  could  send, 
llesplendent  Orb,  but  late  thy  dawning  ray, 
Hath  broke  the  horrors  of  a  sunless  day, 
Soon  may  thy  power,  our  languid  spirits  fire, 
And  Franklin's  sons  to  classic  heights  aspire, 
An  Attic  genius  stamp  our  growing  fame, 
And  wrest  the  Laurels  even  from  Grecian  name, 
Then  Superstition  from  the  earth  be  cast, 
Not  least  of  evils,  though  to  die  the  last." 

His  style  was  simple,  the  style  of  a  strong,  logical  thinker.  His  theologi- 
cal writings,  though  sometimes  dull,  addressed  to  the  reason,  at  times  swell 
into  beauty,  and  touch  the  conscience.  When  contending  for  some  princi- 
ple or  for  personal  interests,  his  opponents  often  felt  the  keenness  of  his  re- 
buke, and  feared  again  to  call  forth  his  withering,  caustic  words.  In  his 
writings  as  in  his  life,  there  were  no  artful  flourishes  of  rhetoric,  nothing  but 
the  language  of  a  naturally  frank  and  honest  hearted  man. 


BIOGRAPHICAL    SKETCH.  XXI 

All  bombast  in  language  felt  the  keen  edge  of  his  -sarcasm,  and  of  his 
judgment.  No  high  sounding  words  could  captivate  his  approval.  In  his 
lectures  he  was  familiar,  his  illustrations  simple,  adapted  to  give  the  idea, 
rather  than  please  the  fancy. 

Dr.  Newton  was  a  conscientious  man.  To  the  guidance  "of  the  Supreme 
Intelligence  he  intrusted  all  his  interests.  In  every  condition  of  life  he  was 
trust-worthy,  never  deceiving  with  subtle  tongue,  nor  flattering  the  gross 
prejudice  of  the  vicious  and  ignorant.  Rather  than  resort  to  the  duplicity 
which  every  where  prevails  around  us,  he  chose  to  be  deprived  of  many  ad- 
vantages which  an  unmanly  policy  often  affords.  Honest,  open-hearted  and 
unsuspecting  himself,  he  sometimes  gave  his  confidence  to  those  not  worthy 
of  its  reception. 

lie  was  ambitious  to  excel,  ambitious  to  occupy  that  station  for  which  his 
education  and  talents  best  fitted  him.  Would  he  have  served  under  the 
banner  of  those  who  were  his  inferiors  in  qualification  ?  would  he  submit  to 
be  transformed  into  an  instrument  whose  use  would  elevate  ignorance  and 
quackery  above  himself?  Dr.  Newton's  dignity  and  self-respect,  could  not 
be  thus  degraded.  And  if  to  exercise  those  qualities,  is  to  be  ambitious, 
then  he  may  prove  guilty  to  the  charge.  Such  an  ambition  is  worthy  of  all 
honor,  and  respect.  That  ambition  which  never  feels,  moves,  acts,  never 
makes  humanity  rejoice.  His  .ambition  then  was  one  of  the  qualities  which 
fitted  him  for  the  performance  of  the  duties  devolving  upon  the  station  which 
he  occupied.  Its  results  have  added  to  the  interests  of  progressive  medi- 
cine, and,  therefore,  let  reform  be  thankful  that  a  shining  light  has  illumined 
its  rising  pathway  to  usefulness  and  honor. 

His  affections  were  strong.  When  once  entwined  around  their  object, 
they  were  enduring  and  constant.  He  loved  strongly,  loved  the  qualities 
which  make  up  the  ideal  of  perfection,  and  in  whomsoever  these  shone 
brightest  and  most  constant,  thither  his  affections  were  directed.  Relatives 
and  friends,  neighbors  and  citizens  loved  him,  for  in  him  the  good  found  en- 
during friendship.  lie  never  sought  to  betray  for  policy,  nor  loved  to  sac- 
rifice the  interests  of  others  for  personal  aggrandizement.  With  him  the 
just  and  good  found  sympathy.  But  the  vicious,  base,  and  jealous  enemy, 
no  regard  and  favor. 

"  Lofty  and  sour  to  those  that  loved  him  not, 
But  to  those  that  sought  him,  sweet  as  summer." 


XX11  BIOGRAPHICAL    SKETCH. 

He  was  a  cheerful  man,  and  loved  to  make  company  lively  by  the  inter- 
change of  wit.  His  mirthfulness  was  peculiar,  breaking  out  in  that  explo- 
sive hearty  laugh,  which  will  long  be  remembered'  by  his  friends  and  ac- 
quaintance. 

Philanthropy  was  one  of  his  qualities  of  mind.  He  heard  the  cry  of  the 
poor,  and  from  his  heart  went  forth  the  bright  stream  of  sympathy  and  re- 
lief. Charity  often  entered  his  open  purse,  and  took  away  that  which  ava- 
rice would  hold  with  relentless  grasp. 

He  was  a  religious  man,  a  Christian  in  the  highest  sense  of  that  word. 
For  its  external  form,  its  pomp  and  show,  he  had  less  regard  than  for  its 
inner  life.  His  soul  had  been  renewed,  and  away  in  the  gloom  of  futurity, 
he  saw  the  golden  gate  open  for  its  reception.  In  all  his  actions  he  recog- 
nized an  overruling  Hand,  and  willingly  submitted  to  Supreme  dictation. 
In  fine,  his  whole  life  shows  that  he  had  a  large  development  of  those  relig- 
ious faculties  which  join  the  hearts  of  the  good  to  the  Infinite  God. 

To  principle  more  than  to  forms  and  ceremonies  he  was  religiously  devoted. 
For  some  benevolent  purpose  he  labored,  not  for  mere  worldly  gain,  but  for 
the  purpose  of  gaining  the  approval  of  a  smiling  humanity.  Having  no 
children  upon  whom  to  bestow  his  care,  he  considered  the  Institution  whose 
corner  stone  he  laid,  as  worthy  of  his  parental  love  and  affection. 

That  he  had  faults  no  one  will  deny,  and  -yet  even  for  these  there  were 
many  palliating  circumstances.  If  he  attempted  too  much,  it  was  because 
he  sought  to  rear  a  fabric  of  medical  reform,  and  to  complete  the  entire 
structure  by  the  force  of  his  own  energy  and  genius.  If  he  did  not  sym- 
pathize with  all  the  ideas  and  customs  of  reformers,  it  was  partly  owing  to 
his  different  culture,  and  different  habits  of  thought. 

Very  few  are  the  men  whose  faults  are  so  few,  whose  virtues  so  many. 
The  clay  may  be  long  ere  another,  so  faithful  to  principle,  integrity  and  to 
science,  will  descend  from  seats  of  honor,  to  labor  in  an  unpopular  cause  for 
the  sake  of  doing  good  to  the  world. 

A  magnanimity  of  soul  far  transcending  the  little  petty  jealousies  that 
divide  the  ranks  of  reform,  is  plainly  shown  by  the  events  of  his  life. 

At  first  we  see  him  an  ambitious  and  honest  youth,  obtaining  the  prize  of 
intellectual  valor  at  the  common  school ;  now  teaching  with  one  hand,  with 
the  other  studying  the  classics,  and  now  entering  the  University,  and  at  the 


BIOGRAPHICAL    SKETCH.  XX111 

end  of  two  years,  returning  to  his  homo  to  bid  an  affectionate  father  a  last 
farewell ;  now  cheered  by  the  benevolence  of  his  neighbors,  now  exulting 
in  the  joy  of  that  hope  which  is  as  an  anchor  to  the  soul ;  then  teaching  a  high 
school  in  Worcester,  and  next  returning  from  Academic  halls  laden  with  the 
honors  of  science  ;  now  entering  the  theological  seminary  and  devoting  his 
talents  and  acquirements  to  the  service  of  God,  and  now  the  village  pastor  ; 
next  the  college  professor,  then  the  theological  teacher,  again  a  pastor,  after- 
ward a  student  of  medicine,  a  practitioner,  a  professor  and  founder  of  a 
medical  institution,  an  author;  and  finally  we  see  him, 

"  The  hale  and  strong,  who  cherished 

Xoble  longings  for  the  strife, 
By  the  -wayside  fall  and  perish, 

Weary  -with  the  march  of  life." 

Born  November  26th,  1800,  he  died  of  typhoid  fever  August  9th,  1853, 
died  in  the  midst  of  useful  labors,  at  a  time  when  victory  over  difficulties 
was  just  before  him. 

But  his  life  was  not  in  vain  ;  it  was  marked  with  achievements  in  the 
field  of  utility.  He  wrought  a  work  which  humanity  will  bless,  for  he  labored 
for  the  interests  of  man  ;  a  work  which  heaven  approves,  for  he  sought  to 
extend  the  religion  of  Christ.  He  had  induced  tho  student  to  press  on  in 
the  path  of  knowledge  and  virtue  ;  he  had  elevated  the  groveling  ideas  of 
youth,  and  had  pointed  them  to  the  benefits  of  thorough  mental  culture  in 
order  to  insure  success  in  the  practice  of  a  profession ;  he  had  taught  them 
to  exercise  their  own  faculties  of  mind,  to  think  and  investigate  for  them- 
selves, rather  than  to  depend  upon  the  authority  of  others  ;  he  had  taught 
the  physician  the  importance  of  possessing  an  unblemished  moral  and  relig- 
ious character.  Of  these  labors  he  began  to  receive  the  reward.  His  ideas 
of  medicine  began  to  enter  the  walks  of  the  higher  circles  of  society,  induc- 
ing legal  protection  and  securing  popular  favor.  Before  his  decease,  he  had 
seen  these  indications  of  the  speedy  and  final  triumph  of  medical  truth  over 
prejudice  and  conservatism.  If  he  did  not  complete  the  entire  fabric,  he 
formed  and  fashioned  the  plan,  laid  the  corner  stone  and  reared  thereon  the 
central  pillar.  The  consciousness  of  having  done  so  much  for  the  good  of 
mankind,  must  have  lighted  with  joy  the  last  moments  of  his  existence. 
Life  to  him  was  desirable  for  its  opportunities  to  do  good  to  others,  and  his 


XXIV  BIOGRAPHICAL    SKETCH. 

regret  was,  that  a  disease  should  take  him  away  from  a  field  of  labor  in 
which  he  was  conscious  of  conferring  a  lasting  benefit  upon  the  world. 

Prophetic  omens  of  the  sad  event  had  appeared.  I  was  with  him  at  Syr- 
acuse, his  room-mate  and  colleague,  and  often  heard  him  remark  "  My  work 
is  nearly  done — adhere  to  me,  carry  out  my  plans."  Death  came  though 
scarcely  welcome.  A  few  faithful  friends  and  medical  attendants  gathered 
around  him  ;  upon  them  he  called  for  aid,  but  for  the  cold  touch  of  death 
there  was  no  healing  balm.  His  strength  failed,  delirium  stirred  up  his 
brain,  and  again  he  hopefully  talked  of  his  College,  his  Journal,  his  Book. 
Finally,  the  silver  cord  was  loosed  and  his  soul  rising  to  newness  of  life  was 
calm  and  peaceful  in  the  bosom  of  God. 

Such  washis  life  ;  his  physical,  vigorous,  and  energetic  ;  his  intellectual,  in  its 
onward  flow  constructs  a  more  accessible  pathway  to  scientific  truth ;  his 
moral  and  religious,  like  a  cone  its  apex  at  the  earth,  its  base  in  the  light  of 
eternity  is  ever  expanding,  ever  progressing  in  the  bright  sunbeams  of  the 
Pure  Intelligence. 

He  is  no  longer  a  citizen  of  earth ;  but 

There  is  a  happier  clime, 

A  larger  and  a  purer  life,  unknown  to  earth  and  time, 
A  clime  with  light  ineffable,  unveiled  by  midnight  gloom, 
Beside  whose  living  streams  the  fairest  flowers  perennial  bloom  ; 
A  clime  beyond  the  circling  stars,  the  floating  cloud,  the  sky, 
All  radiant  with  its  glowing  hues  ;  there  all  beneath  it  lie, 
There  with  the  loved  and  lost  of  earth,  undestined  more  to  sever, 
In  their  glad  presence  shall  he  dwell,  in  blessedness  forever. 


THORACIC  DISEASES. 


Any  classification  of  the  diseases  to  which  the  human  body  is 
subject  must  necessarily  be,  to  an  extent,  artificial  and  imperfect. 
Both  advantages  and  disadvantages  attend  every  arrangement 
which  ever  has  been,  or  ever  can  be  adopted.  In  what  I  may 
say  in  this  volume,  and  in  others  which  I  intend  (Deo  volente] 
to  succeed  it,  I  shall  employ,  in  the  main,  a  topographical  divis- 
ion. 

As  the  subject  of  this  volume  I  have  selected  THE  VARIOUS  DIS- 
EASES BELONGING  TO  THE  CAVITY  OF  THE  THORAX  ;  but,  passing 

down  the  cervix  to  exclude  cervical  diseases,  where  shall  I  begin 
my  reckoning  of  thoracic  ?  It  best  suits  my  convenience  to  com- 
mence at  the  bifurcation  of  the  trachea,  that  is,  at  the  origin  of 
the  right  and  left  primary  bronchi.  I  pause  upon  that  separating 
muscle,  the  diaphragm. 

Having,  however,  bounded  the  field  of  my  observation,  I  find 
myself  at  a  loss  in  examining  the  objects  within.  Some  of  the 
diseases  here  observed  are  of  such  a  nature  as  to  exist  only  in 
this  locality:  others  imply  an  affection  common  to  the  thorax  and 
other  parts  of  the  body ;  while  others  still  are  only  local  manifes- 
tations of  a  morbid  influence  pervading  the  whole  system.  In 
my  classification,  I  shall  embrace  all  those  affections  which  are 
quite  prominently  exhibited  in  the  thoracic  cavity. 


18  THORACIC    DISEASES. 


PART    I. 

GENERAL    CONSIDERATIONS. 

Before  proceeding  to  a  particular  description  of  the  several  dis- 
eases appertaining  to  the  thorax,  various  abstract  principles  and 
preliminary  matters  require  some  illustration.  On  such  topics  as 
are  but  remotely  connected  with  these  diseases,  or  are  readily  un- 
derstood, the  medical  reader  must  be  left  to  inform  himself  from 
other  sources ;  and  the  following  pages  take  it  for  granted,  that,  as 
far  as  these  topics  have  a  bearing  on  the  primary  subject  of  this 
work,  the  labor  of  proper  investigation  has  already  been  performed. 
Other  topics,  however,  of  the  first  importance,  are  of  such  a  nature 
as  to  demand  here  a  somewhat  full  discussion. 


DIVISION  I. 

PATHOLOGY. 

Pathology  treats  of  whatever  relates  to  the  physical  system  in 
a  state  of  disease.  In  its  most  limited  application,  it  implies  a  de- 
scription of  altered  structures  or  morbid  conditions.  In  a  more 
enlarged  sense,  however,  it  involves,  besides  this  consideration,  an 
explanation  of  the  processes  by  which  the  existing  condition  is 
produced, — also,  of  the  causes  by  which  those  processes  have 
been  established,  and  of  the  consequences  of  that  condition,  or 
the  symptoms  occasioned. 

My  present  purpose  does  not  require  nor  allow  an  extensive 
discussion  of  pathological  principles.  I  limit  myself  to  such  mat- 
ters as  are  quite  intimately  connected  with  diseases  of  the  thorax  ; 
but,  in  illustrating  them,  I  am  obliged  to  dwell  a  little  on  some 
considerations  which  are  in  themselves  strictly  physiological. 


FEVER.  19 


CHAPTER  I. 

FEVER. 

The  term  fever,  in  its  original  application,  as  is  evident  from  the 
import  of  the  corresponding  word  in  Latin  and  in  several  modern 
languages,  signifies  heat.  From  this  sense,  however,  a  wide  de- 
parture has  long  since  been  taken.  When  the  nosological  system 
of  classification  universally  prevailed,  the  term  was  used  to  indi- 
cate a  certain  collection  of  symptoms,  such  as  an  abnornal  degree 
of  heat  in  the  body,  an  accelerated  pulse,  a  furred  tongue,  and  a 
generally  impaired  state  of  the  corporeal  functions.  Inasmuch, 
however,  as  very  different  pathological  conditions  may  produce 
these  symptoms,  Cullen,  at  a  somewhat  later  period,  chose  the 
the  term  pyrexia  to  mark  these  constitutional  disturbances  when 
arising  from  some  local  cause ;  and  he  limited  the  former  term  to  the 
designation  of  similar  symptoms,  when  the  cause  is  some  general 
and  not  well  understood  influence  upon  the  physical  system.  It 
would  be  well  now  for  the  interests  of  medical  science,  if  the  pro- 
fession would  favor  this  distinction.  At  any  rate,  to  avoid  confu- 
sion of  ideas,  it  is  indispensible  to  remember,  that  the  term  is  em- 
ployed to  indicate  symptoms  which  arise  from  very  dissimilar 
causes. 

When  the  cause  is  inflammation  or  any  local  disturbance,  what- 
ever, I  call  the  constitutional  excitement  symptomatic  fever,  or 
pyrexia.  On  the  contrary,  when  the  cause  is  the  existence  of  mor- 
bific matter  in  the  current  of  the  circulation  (, whether  this  has 
been  introduced  from  the  atmosphere  without,  or  by  means  of 
mal-assimilation  within  the  system),  I  designate  the  disturbance  as 
idiopathic  fever,  or  fever  more  properly  so  called. 

In  the  former  case,  that  of  pyrexia,  the  term  employed  is  nec- 
essarily applied  to  the  manifestations  of  disease  ;  and,  when  the 
cause  is  purely  imnammation  of  some  part,  the  constitutional  man- 
ifestations of  that  cause  are  sometimes  characterized  as  inflamma- 
tory fever, — the  phrase  being  used  in  a  sense  somewhat  more  limit- 
ed than  that  of  symptomatic  fever.  In  the  sense  of  idiopathic 


20  THORACIC    DISEASES. 

fever,  the  term  should  be  understood  to  involve  more  immedi- 
ately certain  pathological  conditions  as  giving  rise  to  that  consti- 
tutional excitement  which  manifests  those  conditions. 

If  this  distinction  should  be  rigidly  observed,  the  term  fever 
would  distinctly  characterize  a  class  of  diseases,  pathologically 
considered ;  and  all  controversy,  in  regard  to  the  recuperative  ef- 
forts of  nature  as  constituting  fever,  would  be  forever  at  an  end. 
In  this  sense,  however,  the  term  embraces  an  extensive  and  im- 
portant subject, — one  which,  though  concerned,  to  some  extent, 
with  thoracic  diseases,  yet  more  appropriately  belongs  elsewhere, 
and  which  I  design  to  discuss  at  length  in  another  volume.  In 
the  sense  of  symptomatic  fever  orpyrexia,  as  the  subject  only  in- 
volves directly  the  manifestations  of  existing  local  disease,  it  does 
not  require  any  separate  discussion. 


CHAPTER  II. 

INFLAMMATION. 

Inflammation  is  a  term  derived  immediately  from  inflammatio, 
a  Latin  word,  the  root  of  which  is  injlammo,  to  burn  or  inflame. 
It  is  applied  to  a  local  disease,  one  prominent  characteristic  of 
which,  is  an  abnormal  degree  of  heat. 

That  some  things,  connected  with  the  nature  and  manifesta- 
tions of  this  disease,  are  complicated,  and  have,  till  of  late,  been 
involved  in  intricacy,  I  freely  admit.  In  its  most  prominent  fea- 
tures, however,  it  is  exceedingly  simple ;  and  one  cannot  avoid 
the  emotion  of  wonder,  that  numerous  pages  and  even  volumes 
have  heretofore  been  written  with  little  effect,  except  to  make 
gross  darkness  the  more  visible.  In  the  theories  of  medicine,  in- 
deed, as  in  those  of  theology,  much  talent  has,  on  different  topics, 
been  wasted  in  dreamy  speculations.  The  more  acute  have  been 
the  intellects  employed,  the  more  delicately,  it  is  true,  have  hairs 
been  split,  but  the  less  has  been  the  amount  of  practical  common 
sense  exhibited.  We  need  not  historically  come  down  to  the 
days  of  Hahnemann,  and  of  sugar  globules,  represented  to  possess 
power  in  proportion  as  they  approach  an  infinitesimal  division. 


INFLAMMATION.  21 

Homoeopathy  may  be,  indeed,  the  quintessence  of  professional 
nonsense ;  but  that  which  is,  at  least,  double-refined,  has  existed 
from  an  earlier  period  than  any  portion  of  the  present  century. 

This  lamentable  truth  has  been  made  more  evident  on  no  sub- 
ject than  on  that  of  inflammation.  More  than  one  hundred  and 
fifty  years  since,  Boerhaave  taught  the  luminous  doctrine,  that 
inflammation  is  caused  by  viscidity  of  the  blood,  and  an  error  loci 
of  its  particles,  together  with  a  morbidly  acrimonious  state  of  the 
fluids.  Next  come  the  fanciful  and  frivolous  notions  of  Stahl  and 
Hoffman  respecting  the  influence  of  the  nervous  system  in  pro- 
ducing inflammation.  Passing  forward  to  the  middle  of  the 
eighteenth  century,  we  find  Cullen  maintaining  the  theory,  that, 
in  inflammation,  there  is  an  obstruction  of  the  blood,  produced  by 
''spasm  of  the  extreme  arteries,  supporting  an  increased  action  in 
the  course  of  them."  Hunter,  who  was  nearly  contemporary  with 
Cullen,  supposed,  that,  when  inflammation  exists,  there  is  "a  dis- 
tracted state  of  parts,  which  requires  another  mode  of  action  to 
restore  them  to  a  state  of  health."  This  other  and  necessary 
mode  he  considered  inflammation  to  be.  Of  course,  in  his  opin- 
ion, it  was  a  recuperative  and  not  a  morbid  process. 

Of  late  years,  considerable  controversy  has  been  raised,  by  two 
conflicting  and  almost  opposite  opinions  on  this  subject.  One  of 
these  opinions  makes  inflammation  depend  on  "increased  action 
of  the  capillaries  of  the  part;"  the  other,  on  "weakened  action  of 
the  same  vessels,  and  increased  action  of  the  trunks."  In  support 
of  the  one  or  the  other  of  these  opinions,  English  physicians,  no 
less  distinguished  than  Dr.  Thomson,  Sir  Everard  Home,  Dr. 
Wilson  Philip,  and  others  of  equal  professional  rank,  have  adduced 
their  own  experiments  on  living  animals;  but  these  experiments, 
though  convincing  to  their  authors,  do  not,  as  they  are  now 
viewed,  establish  either  of  the  opposing  theories. 

Dr.  George  Hay  ward  of  Boston,  late  "Professor  of  the  Princi- 
ples of  Surgery  and  Clinical  Surgery,"  in  the  Medical  Depart- 
ment of  Harvard  University,  has  been  accustomed,  in  his  Medical 
Lectures,  to  define  inflammation  to  be  "a  diseased  action  of  the 
capillary  vessels,  attended  by  redness,  swelling,  pain,  and  heat." 
In  this  definition,  the  Professor  has  certainly  manifested  talent, 
lying  in  one  direction.  In  other  words,  he  has  shown  ability  to 


22  THORACIC    DISEASES. 

speak  with  such  vagueness,  that,  while  he  seems  to  utter  an  im- 
portant sentiment,  he  really  says  nothing  definite  or  of  moment. 
Except  those  who  embrace  that  absurd  Hunterian  notion,  that 
inflammation  is  a  process  of  recovery  or  increased  physiological 
action,  none,  of  course,  can  doubt,  that,  in  it,  there  is  an  abnor- 
mal condition  of  the  capillaries,  and  that  redness,  swelling,  pain, 
and  heat  are  phenomena  attending  the  local  disturbance ;  but 
What  is  the  disease  of  the  capillaries?  and  What  is  the  proximate 
cause  of  those  phenomena?  These,  and  like  questions,  the  only 
ones  of  importance  in  the  case,  are  left  wholly  untouched.  Be- 
sides, the  same  high  authority  has  uniformly  taught  the  medical 
students  of  the  University,  that,  in  the  healing  of  a  wounded 
part,  the  first  recuperative  process  established  is  inflammation,  and 
that,  without  this,  neither  an  adhesion  nor  healthy  granulations  can 
be  formed.  In  other  words,  the  language,  if  I  understand  it,  says, 
that,  where,  from  any  cause,  there  is  a  solution  of  continuity  in 
any  of  the  tissues,  the  first  part  of  the  curative  process  is  a  par- 
ticular morbid  action.  So  much  for  medical  philosophy  and  con- 
sistency ! 

Having  thus  remarked  upon  the  absurdities  of  those  medical 
opinions  which  have,  at  different  times,  been  entertained  for  nearly 
two  centuries  past,  and  having  done  this  to  show  what  inflamma- 
tion is  not,  it  becomes  me  now  to  attempt  an  illustration  of  what 
it  is.  I,  therefore,  immediately  define  inflammation  to  be  a  state 
in  which  the  capillaries  of  the  part  affected  are  interrupted  in  their 
proper  function,  are  morbidly  relaxed,  and  are  over-distended;  and, 
in  which  the  blood  that  is  passing  through  them  is  first  abnormal- 
ly excited  and  chemically  changed,  and  then  stagnates  and  coagu- 
lates. This  definition  supposes  a  pathological  and  not  a  mere 
symptomatic  view  of  the  disease.  Its  symptomatology  would 
merely  say,  that  it  consists  in  redness,  swelling,  pain,  and  heat, 
as  these  are  the  phenomena  immediately  attending  it. 

Here  I  would  remark,  that  the  nosological  classification  of  dis- 
eases, formerly  adopted  by  the  profession,  contemplated  them, 
almost  exclusively,  as  different  groups  of  symptoms.  The  symp- 
toms at  any  time  existing,  collectively  considered,  were  called  the 
disease.  The  causes  of  these  symptoms  were  divided  into  proxi- 
mate and  remote.  The  proximate  were  what  we  now  call  the 


INFLAMMATION.  23 

disease  itself, — that  is,  the  pathological  condition  giving  rise  to 
the  symptoms.  The  remote  causes  were  sub-divided  into  excit- 
ing and  predisposing.  The  exciting  were  those  which,  by  their 
immediate  action,  developed  the  pathological  symptoms.  The 
predisposing  were  all  such  influences  as  prepared  the  system  to 
be  affected  by  the  action  of  immediate  agencies. 

In  illustrating  the  disease  now  before  me,  I  propose  to  consider 
its  inherent  nature,  its  causes,  and  its  effects.  In  regard  to  the 
first  of  these  particulars,  I  remark,  that,  when,  for  any  cause,  the 
nerves  connected  with  the  contractile  fibrous  tissue  of  the  capilla- 
ries lose  their  power,  the  tension  of  the  coats  of  the  vessels  is  not 
preserved,  and,  as  the  consequence,  the  relaxation  is  immediately 
manifested  by  those  vessels'  becoming  abnormally  filled.  This,  I 
suppose,  to  be  the  usual  way  in  which  capillary  congestion  is  ef- 
fected. The  relaxation  is  primary,  and  the  over-distention  secon- 
dary. The  process  may,  however,  and  sometimes  doubtless  does, 
commence  in  the  opposite  direction.  Arterial  excitement,  by  in- 
creasing abnormally  the  current  of  the  blood,  may  mechanically 
force  open  the  capillaries,  and  the  relaxation  may  occur,  seconda- 
rily, as  the  effect  of  over-distention,  in  destroying  the  innervation. 
The  former  of  these  modes  Dr.  C.  J.  B.  Williams  calls  that  of 
congestion ;  the  latter,  that  of  determination  of  the  blood.  Both 
causes,  may,  indeed,  exist  at  the  same  time.  The  vessels  may 
morbidly  relax  and  arterial  excitement  may  occur  simultaneously. 

But,  in  whichever  manner  the  fulness  or  congestion  of  the 
capillaries  takes  place,  it  can  seldom  be  allowed  long  to  remain 
without  producing  the  characteristics  of  inflammation.  There 
may,  however,  for  a  season,  be  capillary  congestion  without  in- 
flammation ;  but  there  cannot  be  inflammation  without  capillary 
congestion,  as  a  primary  part  of  the  process.  Capillary  conges- 
tion is  not  inflammation,  but  inflammation  is  capillary  congestion 
and  something  more. 

In  the  commencement  of  inflammation,  as  the  capillary  vessels 
are  beginning  to  be  clogged,  the  onward  current  of  blood  is,  of 
course,  partially  obstructed,  and  perturbation  follows.  When  the 
part  concerned  is  microscopically  examined,  the  white  globules 
and  the  red  corpuscles  are  seen  passing,  for  a  time,  in  different 
directions, — onward,  backward,  and  obliquely.  Soon  the  white 


24  THORACIC    DISEASES. 

globules,  which  pass  not  so  centrally  in  the  current  as  the  red 
corpuscles,  begin  to  adhere  to  the  walls  of  the  capillaries.  As 
the  disease  advances,  the  relaxed  vessels  having  become  distended 
to  their  utmost,  by  the  stagnated  blood,  doubtless  sometimes  suffer 
a  portion  of  it  to  be  effused  or  extravasated  into  the  circumjacent 
areolar  tissue.  When  this  takes  place,  that  which  has  left  the 
vessels  soon  coagulates  and  becomes  foreign  matter.  Indeed,  its 
coagulation  is  the  same  as  that  of  blood  drawn  into  a 'cup,  in 
ordinary  venesection. 

But  the  blood  within  the  vessels  is  the  only  portion  of  special 
importance  to  be  considered;  and  this  is  the  subject  of  very  pe- 
culiar and  interesting  changes,  worthy  of  a  more  minute  descrip- 
tion. The  functions  of  secretion  and  nutrition,  in  connection 
with  the  part  affected,  being  partially  or  wholly  arrested,  it  would 
seem,  that  the  nervo-vital  power  usually  employed  in  those  func- 
tions, is  not  supplied,  or  passes  in  another  direction;  and  the  elec- 
tricity, set  free  by  the  union  of  carbonic  or  proteine  matter  in  the 
capillaries  with  the  oxygen  contained  in  the  red  corpuscles  is  ex- 
pended within  the  current  itself. 

In  this  process,  the  fibrine  is  immediately  increased.  Probably 
this  is  due  to  an  arrest  of  secretion  and  nutrition,  not  merely  in 
the  part  inflamed,  but,  to  an  extent,  sympathetically  throughout 
the  system.  That  there  is  such  a  general  arrest  is  evident  from 
the  symptomatic  fever  or  constitutional  disturbance  which  takes 
place. 

The  white  or  lymph  globules,  too,  are  soon  found  in  an  abnor- 
mal quantity.  Chemically,  these  globules  consist  of  the  deutox- 
ide  of  proteine.  Their  organization,  however,  seems  to  involve 
a  degree  of  vitality.  They  are  spheroidal  bodies  of  gelatinous 
consistency;  and,  indeed,  have  clearly  the  characteristics  of  large 
and  crudely  formed  cells.  At  any  rate,  they  are  made  up  of  gran- 
ules in  such  a  way  as,  in  their  more  perfect  state,  if  not  in  every 
instance,  to  possess  nuclei  and  cell  walls.  They  have  a  strong 
disposition  to  adhere  to  one  another  and  to  the  walls  of  the  ca- 
pillaries. 

Hitherto  physiologists  have  supposed  these  globules  to  be  the 
red  or  blood  corpuscles  .in  a  forming  condition.  In  my  judgment, 
however,  they  are  entirely  distinct,. are  formed  in  a  different  way, 


INFLAMMATION.  25 

and  for  very  different  purposes.  The  red  corpuscles  are  much 
larger  than  the  white  globules, — are  different  in  form  and  in  struc- 
ture. The  former  are  discoid  in  shape  and  have  no  nuclei.  Be- 
sides a  proteine  compound,  they  contain  iron  and  the  various 
incidental  and  stimulating  elements  of  the  blood ;  and  their  spec- 
ial office  seems  to  be  to  convey  oxygen  from  the  atmosphere  to 
the  capillaries,  to  create  animal  heat,  set  electricity  free,  and,  by  a 
stimulating  effect,  give  rise  to  vital  action.  They  have  their  ori- 
gin in  the  blood-vessels,  and,  in  these  vessels,  serve  their  purpo- 
ses, and  perish. 

The  white  globules,  on  the  contrary,  are  evidently  formed  from 
liquid  fibrine,  by  the  oxidizing  process  which  makes  a  solid  deu- 
toxide.  Fibrinization,  we  know,  commences  at  the  lacteals,  and 
increases  throughout  the  course  of  the  lymphatics,  till  the  current 
of  united  lymph  and  chyle  is  passed  into  the  venous  system,  at 
the  terminus  of  the  thoracic  duct.  Fibrine  is  polarized  or  partial- 
ly organized  albumen.  To  my  own  mind,  there  seems  good  rea- 
son for  the  belief,  that  the  elementary  granules  of  vital  being 
have  their  origin  in  the  lymphatic  glands,  and  pass  with  and  as  a 
part  of  the  fibrine,  into  the  current  of  the  blood;  so  that  fibrine, 
not  merely  is  chemically  organized,  but  has  the  first  traces  of  vital 
organization.  If  a  portion  of  chyle  or  any  nutritious  matter  enters 
the  blood,  as  it  would  seem  that  it  does,  by  venous  absorption, 
and  without  passing  through  the  lymphatic  system,  this  may  aid 
in  the  chemical  formation  of  the  red  corpuscles,  or  it  may  be  vi- 
talized, by  the  power  of  the  elementary  granules,  while  in  the 
blood  vessels. 

Be  the  truth,  however,  in  regard  to  these  latter  speculations,  as 
it  may,  it  is  now  certain,  that,  in  inflammation,  white  globules 
exist,  in  abnormal  amount,  in  the  capillaries  of  the  part  affected, 
and  they  are  actually  formed  in  those  capillaries.  It  is,  also,  cer- 
tain, that  these  globules  adhere  to  one  another  and  to  the  walls  of 
the  affected  vessels,  thereby  producing  partial  or  entire  stagnation 
of  the  blood.  During  the  process  of  the  chemical  change,  the 
circulation  of  the  blood  is  disturbed  and  the  motion  of  its  parti- 
cles is  quickened.  As  soon,  however,  as  the  vessels  are  fully 
obstructed,  the  current  necessarily  ceases,  and  the  blood  coagu- 
lates. When  this  takes  place  in  some  of  the  capillaries,  the  sur- 
4 


26  THORACIC    DISEASES. 

rounding  ones  receive  the  current  by  the  anastomosing  vessels. 
and,  of  course,  are  subjected,  for  the  time,  to  an  increased  circu- 
lation;  but,  in  their  turn,  they  are  liable  to  be  obstructed,  and  be- 
come the  recipients  of  stagnant  and  coagulated  blood. 

This  disposition  of  the  white  globules  to  adhere  to  the  walls 
of  the  capillaries  has  been  ascribed  to  the  existence  of  vital  at- 
traction;  but,  probably,  it  is  only  the  result  of  that  physical  prop- 
erty of  adhesiveness  which  belongs  generally  to  solt  solids  com- 
posed of  glutinous  materials.  At  any  rate,  whatever  may  be  the 
immediate  cause  of  the  adhesion,  the  effect  is,  at  length,  to  arrest 
all  vital  action  in  the  part,  and  produce  coagulation. 

As  for  the  red  corpuscles,  during  the  process  of  obstruction, 
they  remain  for  a  season  free,  passing  tortuously  in  the  midst  of 
surrounding  white  globules.  At  length,  however,  they  have  no 
longer  space  to  move,  and  are  so  crowded  into  the  interstices  of 
the  white  globules,  that  the  whole  vessels  concerned  contain  a 
large  accumulation  of  them.  The  liquid  fibrine  and  serum  pass 
on,  or  are  literally  filtered  out. 

The  CAUSES  of  inflammation  may  be  divided  into  predisposing 
and  exciting.  The  predisposing  are  the  influences  which  prepare 
the  system,  or  some  particular  part  of  it,  to  take  on  inflammatory 
action.  They  are  exceedingly  various,  and  their  specification,  in 
this  connexion,  is  entirely  unnecessary. 

The  exciting  causes  demand  a  hasty  consideration  here.  They 
are  mainly  contusion,  friction,  heat,  cold,  venous  compression, 
and  the  absorption,  into  the  blood,  of  morbific  matter. 

Contusion  becomes  a  cause  of  inflammation  by  an  exhaustion 
of  nervous  energy,  or  a  destruction  of  nervous  fibres,  and  an  in- 
terference with  their  action;  so  that  the  vessels  readily  assume  a 
morbidly  relaxed  and  over-distended  condition.  In  this  condition 
there  may  be  effusion;  or  the  cause  may  even  rupture  a  portion 
of  the  vessels,  and  afford  unnatural  outlets  to  the  blood.  This  is 
called  extravasation ;  and  it  often  attends  inflammation,  when 
resulting  from  the  cause  now  under  consideration. 

The  operation  of  friction  is  similar  to  that  of  contusion.  The 
nervous  energy  is  exhausted  or  the  nervous  fibres  are  impaired, 
and  the  capillary  vessels  are  weakened,  so  as  to  prevent  their 
proper  action  in  passing  the  blood  along  to  the  veins.  The 


INFLAMMATION.  27 

effect,  of  course,  is  congestion ;  and,  if  long  continued,  inflam- 
mation. 

Excessive  heat,  applied  to  a  part,  produces  inflammation  there, 
much  after  the  manner  of  contusion  and  friction,  hy  overcoming 
the  nervous  energy  and  impairing  the  action  of  the  capillaries. 
Local  inflammation,  in  a  remote  part,  however,  may  be  produced 
by  such  an  application  of  heat  as  affects  the  constitution  generally 
and  creates  arterial  excitement.  The  balance  between  the  flow  of 
blood  into  the  capillaries  and  that  from  them  being  destroyed, 
over-distention  and  morbid  relaxation,  with  the  various  character- 
istics of  inflammation,  follow. 

Cold,  philosophically  considered,  is  a  mere  negation — the  ab- 
sence of  heat;  but,  in  common  language,  when  the  temperature 
of  the  atmosphere  is  moderate  and  becoming  less,  we  speak  of  an 
increase  of  cold.  Using  the  term,  thus,  in  the  popular  sense,  I 
speak  of  the  effect  of  an  excessive,  local  application  of  cold  as  im- 
pairing the  nervous  energies  of  the  capillaries,  and,  as  in  the  pre- 
ceeding  instances,  giving  rise  to  supervening  inflammation.  Cold, 
so  applied  as  to  act  constitutionally,  may  inflame  a  remote  part,  by 
destroying,  as  in  the  case  of  excessive  heat,  the  balance  of  the 
circulation. 

The  immediate  effect  of  the  compression  of  a  vein  is  congestion 
of  that  vessel,  in  the  part  through  which  the  blood  is  approaching 
the  point  of  compression;  and,  if  the  congestion  is  continued  for 
any  length  of  time,  an  effusion  of  serum  into  the  circumjacent 
areolar  tissue  ordinarily  follows.  Sometimes,  however,  the  com- 
pression, and,  more  especially,  the  obliteration  of  a  vein,  extending 
a  congested  condition  back  to  the  capillaries,  and  disturbing  vital 
action,  gives  rise  to  inflammation. 

But  the  most  fruitful  and  important  source  of  inflammation,  is 
a  depraved  condition  of  the  blood.  The  absorption  of  morbific 
matter,  of  almost  any  kind,  so  renders  the  circulating  fluid  an  un- 
healthy stimulus  to  the  nerves,  that  inflammation  supervenes,  as 
the  consequence.  It  would  seem,  that,  owing  to  some  chemical 
or  other  affinity,  on  the  part  of  different  ingredients  in  the  blood, 
for  different  tissues  or  organs,  the  localities  of  the  inflammation 
created  are  varied  according  to  the  nature  of  the  causes.  In  gen- 
eral, however,  it  will  be  found,  that,  when  local  inflammations 


28  THORACIC    DISEASES. 

take  place  as  the  effect  of  an  abnormal  condition  of  the  blood, 
that  blood  is  too  rich  in  fibrine  absolutely,  or,  at  any  rate,  in  pro- 
portion to  the  amount  of  corpuscle's.  Thus,  while  inflammation 
uniformly  gives  rise  to  an  increase  of  fibrine,  a  quantity  abnormally 
great,  already  existing  in  the  blood,  favors  the  local  development 
of  inflammation. 

The  fibrine,  in  connexion  with  the  primary  granules  which  ac- 
company, and  perhaps  elaborate  it.  is  that  part  of  the  blood  which 
supplies  the  natural  waste  of  the  tissues,  and  repairs  those  tissues, 
when  wounded.  The  red  corpuscles,  on  the  contrary,  supply  the 
nervous  ganglia  with  electricity,  or  the  material  necessary  for  those 
ganglia  to  employ,  in  creating  nervo-vital  fluid. 

The  fibrine  evidently  affords  the  base  for  the  formation  of  that 
deutoxide  compound  called  the  white  globules.  These  globules, 
therefore,  though  in  part,  perhaps,  a  chemical  combination,  are  yet 
in  part,  at  least,  vitally  organized, — the  vital  power,  it  would  seem, 
being  supplied  by  the  products  of  the  lymphatic  glands.  The  red 
corpuscles,  on  the  other  hand,  being  too  abundant,  in  any  case,  in 
proportion  to  the  fibrine,  we  seldom  have  inflammation  in  any 
part,  but  the  patient  is  liable  to  congestion  of  the  veins,  to  their 
rupture,  and  to  a  consequent  hemorrhage.  This  liability  especial- 
ly exists  in  regard  to  the  brain.  Hence  the  frequency  of  apoplexy 
with  plethoric  persons,  or  those  having  an  excess  of  red  corpuscles 
in  the  blood. 

The  nervo-vital  fluid  being  increased,  is  adapted,  in  itself,  per- 
haps, to  give  additional  strength  to  the  arteries.  Still,  in  inflam- 
mation, there  is  arterial  fulness;  and  this  is  evidently  produced  di- 
rectly by  the  capillary  obstruction  checking  the  onward  current, 
or  by  the  constitutional  excitement  increasing  the  arterial  circula- 
tion. The  exciting  effect  of  the  corpuscles,  on  the  contrary,  is, 
like  the  external  irritation  of  the  atmosphere,  a  mere  chemical  and 
not  a  vital  influence,  and  is,  therefore,  in  undue  proportion,  debili- 
tating and  not  strengthening.  The  fibrine  and  primary  granules, 
when  not  abundant,  being  used  up,  to  a  considerable  extent,  at 
the  capillaries,  the  red  corpuscles,  especially  if  forming  too  large  a 
proportion  of  the  blood,  afford  an  abnormal  irritation  to  the  veins, 
weakening  their  energy,  and  causing  their  over-distention. 

Among  the  EFFECTS  of  inflammation  I  rank,  in  the  first  place,  the 


INFLAMMATION.  29 

various  phenomena  by  which  it  has  been  nosologically  character- 
ized. 

The  redness  is  owing  to  an  increased  amount  of  blood  in  the 
congested  vessels,  with  what  is  sometimes  around  them.  The 
different  shades  of  the  redness  result,  partly,  from  the  different 
proportions  in  the  amount  of  arterial  and  venous  blood  in  the  ca- 
pillaries, and,  partly,  from  the  different  conditions  of  the  same  kind 
of  blood.  Ordinarily  the  color  is  somewhat  scarlet,  because  it  is 
mainly  arterial  blood  which  fills  the  capillaries.  This  is  especial- 
ly true  in  scarlatina,  rubeola,  and  other  eruptive  diseases.  In  the 
active  form  of  superficial  erysipelas,  we  have  a  similar  condition. 
Indeed,  much  that  is  ordinarily  called  erysipelatous  inflammation,  is 
rather  erysipelatous  congestion, — the  blood  remaining  in  the  re- 
laxed capillaries,  and  not  being  coagulated,  nor  having  undergone 
the  chemical  changes  characteristic  of  inflammation.  In  this 
condition,  the  color  of  the  part  effected  is  a  bright  scarlet ;  but, 
as  the  congestion  passes  into  inflammation  proper,  the  color  be- 
comes essentially  that  of  ordinary  inflammation.  After  considera- 
ble exposure  to  violent  cold,  the  part  becomes  congested,  and  the 
color  is  then  purplish.  This  is  because  the  venous  portion  of 
the  vascular  system,  lying  more  superficial  than  the  arterial,  the 
blood  in  the  former  is  so  stagnated  as  to  crowd  into  the  capil- 
laries and  give  the  darkened  shade.  Of  course,  if  inflammation 
proper  becomes  established,  the  same  characteristeric  measurably 
remains.  In  general,  while  the  inflammation  is  in  its  active  state 
and  there  is  considerable  constitutional  excitement,  the  hue  is  flo- 
rid ;  but,  after  the  blood  has  been,  for  some  time,  stagnant,  the 
color  becomes  deeper.  The  presence  of  the  white  globules,  how- 
ever, tends  to  render  the  tinge  lighter,  than  is  the  usual  tinge  of 
simple  congestion.  In  all  cases,  when  the  blood  has  been  coagu- 
lated for  a  considerable  time,  the  color  becomes  darker,  in  conse- 
quence of  the  change  in  the  coagulated  material. 

The  swcllim?  of  inflammation  is  the  result  of  the  accumulation 

o 

of  blood  in  the  part  affected ;  and  it  is  proportioned  to  the  abnor- 
mal amount  detained  in  and  sometimes  around  the  capillary  vessels. 
Of  course,  the  increase  of  the  part  is  essentially  the  same  before 
and  after  the  blood  has  coagulated.  In  connection  with  the  en- 
largement by  inflammation,  there  may  be  and  often  is  a  farther  en- 


30  THORACIC    DISEASES. 

largement  by  other  means,  as  by  oedema,  by  a  congestion  of  the 
lymphatic  vessels,  or  by  a  collection  of  pus;  but,  in  general,  these 
different  effects  are  easily  discriminated.  Different  tissues,  it  is 
true,  are  capable  of  very  different  degrees  of  swelling  by  inflam- 
mation; but  this  is  due  to  the  difference  in  the  vascularity  of 
their  structure  and  in  their  capacity  to  receive  blood.  Mucous 
tissues,  for  instance,  are  more  vascular  than  serous,  and  are,  con- 
sequently, capable  of  more  accumulation  of  blood.  The  same  is 
true  of  the  cutaneous  tissue.  Hence  the  very  appreciable  amount 
of  swelling  shown  in  the  skin,  in  different  eruptive  diseases,  mod- 
ified, however  by  some  of  the  other  circumstances  already  referred 
to.  But  to  the  muscular,  the  areolar,  and  the  glandular  tissues, 
from  the  character  of  their  structure,  we  are  more  especially  to 
look  for  the  greatest  amount  of  enlargement,  when  the  part  is  in- 
flamed. In  these  the  swelling  is,  sometimes,  not  only  considera- 
ble, but  very  great. 

The  pain  of  inflammation  is  produced,  partly,  by  the  tension  of 
the  tissues  or  the  pressure  made  on  the  nerves  of  the  part  affected  : 
and,  partly,  perhaps,  by  an  exaltation  of  the  sensibility  created  by 
the  temporary  arterial  excitement,  or  determination  of  blood.  It 
is  different  in  different  portions  of  the  system,  being  varied  by  the 
degree  of  innervation  and  other  circumstances,  under  the  influence 
of  the  same  immediate  cause.  Let  the  natural  sensibility  of  the 
part  be  acute,  the  arterial  excitement  considerable,  and  the  pres- 
sure strong ; — we  then  have  the  severest  pain,  as  in  inflammation 
of  the  sheath  of  a  nerve,  the  pulp  of  a  tooth,  &c.  Indeed,  when 
the  natural  sensibility  is  not  great,  the  other  circumstances  com- 
bined may  give  distressing  pain ;  as,  for  instance,  when  the  lining 
of  an  osseous  canal  is  inflamed.  The  strong  determination  of 
blood  to  the  part  and  its  confinement  by  pressure  may  so  exalt  the 
sensibility,  though  in  health  it  is  not  great,  as  to  render  the  pain 
most  excruciating. 

The  inflammation  may  be  so  located  and  the  tissues  concerned 
may  be  of  such  a  character,  that  but  little  or  no  pain  is  experi- 
enced, except  when  the  part  is  pressed,  or  its  tissues  are  somehow 
put  upon  the  stretch.  This  condition,  which  is  called  tenderness, 
exists  commonly  in  enteritis,  sometimes  in  pleuritis,  and  indeed  in 
various  affections.  There  are,  under  peculiar  circumstances,  other 


INFLAMMATION.  3 1 

modifications  of  pain  which  are  commonly  called  feelings  of  sore- 
ness, of  smarting,  of  tingling,  of  heat,  &c.;  but  which  need  no 
special  illustration  here.  They  are  the  pain  of  inflammation,  uni- 
ted with  sensations  produced  by  connected  causes. 

The  heat  of  inflammation  presents  a  problem  which,  till  of 
late,  has  not  been  well  solved.  Animal  heat  is  maintained  by  a 
process  of  combustion  or  oxidation.  In  the  lungs,  in  the  act  of 
inspiration,  a  portion  of  the  blood  is  evidently  oxidized,  by  the 
oxygen  inspired,  and  caloric  is  evolved  ;  so  that  arterial  blood  pro- 
ceeding from  the  lungs  is  one  or  two  degrees  warmer  than  the 
venous  which  enters  them.  A  part,  too,  of  the  inspired  oxygen 
is  taken  up,  "  and  is  carried,  by  the  agency  of  "  the  red  corpuscles, 
or  lia  compound  of  iron,  to  every  part  of  the  body."  In  the  ca- 
pillaries, oxidation  again  takes  place,  by  a  union  of  oxygen  with 
either  effete  portions  of  tissue,  or  those  portions  of  the  circula- 
tion which  are  not  in  a  condition  to  be  appropriated  to  nutrition, 
properly  so  called.  The  adipose  tissue  of  the  animal  body,  we 
know,  is  only  the  non-azotized  elements  of  the  food  (,or  such  as 
will  not  form  the  other  tissues  and  nourish  the  system),  organized 
(,when  the  oxygen  present  is  not  sufficient  for  their  immediate 
combustion),  and  deposited,  to  be  used  for  oxidation,  when  after- 
wards needed;  and,  "in  the  herbivorce,  a  great  part  of  the  com- 
bustion which  yields  the  animal  heat  is  carried  on  at  the  expense 
of  those  parts  of  the  food  which  cannot  form  blood ;  namely, 
sugar,  starch,  or  gum,  fat,  &c."  Besides  the  oxygen  which  en- 
ters the  circulation  through  the  lungs,  a  considerable  quantity  is, 
also,  received  into  the  system  by  absorption,  through  the  skin, 
and  mucous  tissues ;  and  this  is,  in  like  .manner,  used  for  the  ox- 
idizing process.  The  immediate  result  «f  this  process  is  the  for- 
mation of  carbonic  acid  and  water,  which  are  disposed  of  mainly 
by  the  lungs  and  by  the  tegumentary  tissue.  The  effect  of  ac- 
tive exercise  is  to  quicken  the  respiration,  and  the  circulation, — 
thereby  impelling  more  blood  and  carrying  more  oxygen  into  the 
capillaries  of  the  surface,  as  well  as  elsewhere.  The  result  of 
this  is  iticreased  oxidation,  it  is  true;  but  a  portion  of  the  acid  and 
the  water,  formed  by  the  invigorated  action  of  the  perspiring  fol- 
licles, passes  upon  the  surface,  in  the  form  of  perspired  matter. 


32  THORACIC    DISEASES. 

The  evaporation  of  this  matter,  in  obedience  to  a  well  known 
chemical  law,  promotes  coolness  at  the  perspiring  part. 

Now,  in  inflammation,  the  perspiring  follicles  are  not  invigora- 
ted by  an  increased  power  of  the  nervous  tissue.  On  the  con- 
trary, that  power  is  weakened  or  destroyed,  the  perspiration  is 
checked  or  prevented,  and  the  cooling  effect  is  diminished  or  lost. 
At  the  same  time,  the  oxidizing  process  is  not  diminished  but  is 
increased.  It  does  not  appear,  that  the  matter  of  the  tissues  be- 
comes more  rapidly  effete.  On  the  contrary,  it  would  even  seem, 
that,  to  an  extent,  the  process  is,  with  that  of  nutrition,  suspen- 
ded. But,  while  the  nervous  power  is  not  used  in  the  ordinary 
secretions  and  excretions  by  which  the  system  is  nourished  and 
changed,  that  same  power  is  evidently  diverted  from  the  nutritive 
to  the  excito-motory  branch  of  the  nervous  system.  Hence  arises 
the  constitutional  excitement,  which  always,  to  an  extent,  attends 
inflammation.  The  respiration  and  the  circulation  are  quickened ; 
the  materials  for  an  increased  oxidation  in  the  capillaries  of  the 
inflamed  part  are  supplied ;  and,  through  the  local  irritation,  an 
unusual  process  of  oxidation,  within  the  capillaries,  is  set  up.  It 
is  that  already  described,  in  which  the  white  globules  are  abnor- 
mally multiplied.  This  process,  from  the  nature  of  chemical 
laws,  must  evolve  heat ;  and  I  suppose  it  to  be  the  principal  source 
of  the  increased  heat  of  inflammation. 

The  fact,  that,  under  constitional  excitement,  the  blood,  heated 
at  the  lungs,  passes  more  rapidly  to  the  inflamed  part,  has,  doubt- 
less, a  slight  influence  in  creating  the  local  heat ;  but  that  the 
cause  is  principally  local,  is  evident  from  the  simple  consideration, 
that,  occasionally,  the  affected  portion  has  a  temperature  of  102, 
104,  and  even  106,  or  more  degrees  of  Fahrenheit. 

In  explaining  the  phenomena  by  which  inflammation  reveals 
itself,  other  effects  have  already  been  referred  to.  One  of  these 
is  the  interruption  of  the  functions  of  secretion  and  nutrition.  In 
health,  the  fibrine,  with  the  primary  granules,  is  constantly  being 
applied  to  the  regeneration  of  the  tissues,  as  the  matter  of  those 
tissues  is  constantly  losing  its  vitality  and  becoming  effete.  But, 
in  inflammation,  it  has  been  already  said,  the  interruption  of  the 
nervous  action  suspends  this  process,  in  the  inflamed  part;  and  it 


INFLAMMATION.  33 

would  seem,  that,  by  sympathy,  it  is,  also,  in  a  great  degree,  sus- 
pended throughout  the  system. 

Hence,  another  consequence  is,  that  Jibrine  accumulates  in  the 
blood, — increasing,  from  less  than  three  parts  in  a  thousand,  not 
unfrequently  to  five,  and,  sometimes,  even  to  seven  or  eight. 

I  ascribe  to  this  cause  the  increase  of  fibrine  characteristic  of 
inflammation,  rather  than  to  any  peculiar  cause  existing  exclusive- 
ly in  the  part  affected.  That  the  white  globules  are  elaborated 
mainly  in  the  part  affected  is  evident;  but  their  elaboration  is  an 
oxidation  of  existing  fibrine,  which  is  a  vitalized  compound. 
The  increase  of  fibrine  is  proportioned  to  the  extent  and  duration 
of  the  inflammation,  in  the  active  state ;  but  so,  also,  are  the  con- 
stitutional disturbance  and  the  suspension  of  the  secreting  and 
nutritive  processes.  That  the  blood  in  the  inflamed  part  contains 
more  fibrine  than  in  others,  may  be  true;  but,  if  so,  as  the  ordi- 
nary vital  processes  are  more  interrupted  there  than  elsewhere, 
this  may  afford  an  explanation  of  the  cause. 

Again,  the  effect  of  the  suspension  of  the  nutritive  function  is, 
that  there  is  no  sense  of  want  in  the  system, — in  other  words,  no 
appetite;  and  the  taking  of  food,  under  the  circumstances,  only 
imposes  a  burden  upon  the  powers  of  nature. 

Here  I  may  remark,  in  passing,  that,  if  the  process  by  which 
effete  matter  is  thrown  off,  is  a  vital  act,  and  governed  by  laws 
similar  to  those  by  which  a  new  deposit  is  made,  then  it  must 
cease,  substantially,  when  the  other  process  is  suspended.  If,  on 
the  other  hand,  it  is  a  mere  chemical  process, — such  as  attends  all 
decay  of  animal  matter, — then  it  will  not  be  effected  by  the  con- 
dition of  the  vital  functions.  Some  facts,  it  seerns  to  me,  strong- 
ly commend  the  former  view  ;  and,  among  these,  the  compara- 
tively slight  diminution  of  the  azotized  tissues,  when,  by  reason 
of  constitutional  disturbance,  the  appetite  is  destroyed,  and  little 
or  no  food  is  taken  for  a  considerable  length  of  time.  In  that 
condition,  it  is  true,  the  adipose  tissue  is  used  up  in  creating  ani- 
mal heat ;  but  it  is  the  consumption  of  that  tissue,  mainly,  which 
produces  any  occurring  emaciation. 

I  have  already  alluded  to  the  suspension  of  superficial  perspira- 
tion as  an  effect  of  inflammation.  This  needs  no  farther  illustra- 
tion than  to  say,  that  the  matter  seems  to  be  governed  by  a  law 


34  THORACIC    DISEASES. 

in  common  with  that  which  controls  the  replenishing  and  the  de- 
trition of  the  tissues. 

There  are  other  effects  of  inflammation;    but,  being  more  re- 
mote and  constitutional,  they  do  not  require  discussion  here. 


CHAPTER  III. 

CONGESTION. 

I  have  spoken  of  inflammation  as  commencing  in  a  congestion 
of  the  capillaries.  When,  however,  we  speak  of  congestion,  as  a 
disease,  we  mean  an  excessive  fulness  of  the  larger  vessels,  and 
commonly  the  veins.  From  the  veins,  when  lying  superficially, 
in  connexion  with  mucous  tissues,  there  seems  sometimes  to  be 
an  effusion  of  blood  as  a  whole,  or  a  hemorrhage,  without  any 
apparent  lesion  of  the  vessels.  This  is  illustrated  in  ordinary 
cases  of  hematemesis,  and  in  some  cases  of  hemoptysis.  It  may, 
however,  be  reasonably  questioned,  whether,  in  these  cases,  there 
is  not  an  actual  rupture  of  the  delicate  coats  of  the  smaller 
veins. 

Be  that  as  it  may,  ordinarily  at  least,  when  blood  leaks  from 
the  veins,  it  is  because  of  a  rupture  of  their  coats ;  that  is,  it  is 
hemorrhage  by  extravasation.  This  rupture,  of  course,  is  the 
effect  of  pressure  and  over-distention.  But  it  is  veins,  and  not 
capillaries,  that  are  the  subject  of  lesion ;  and  the  constitutional 
effects  of  the  hemorrhage  are  very  different  from  those  of  inflam- 
mation. When  the  hemorrhage  is  produced  upon  the  brain,  the 
result  is  apoplexy,  and  not  brain  fever; — when  produced  in  the 
lungs,  it  is  the  disease,  pulmonary  hemorrhage  or  pulmonary  apo- 
plexy, and  not  pneumonitis.  In  short,  whatever  disturbance  it 
may  produce  in  the  system,  it  does  not  give  rise  to  such  an 
amount  of  constitutional  excitement  or  symptomatic  fever,  as  in- 
flammation. Inflammation  is  liable  to  be  caused  by  an  abnormal 
increase  of  fibrine.  Hemorrhage  often  results  from  an  excess  of 
red  corpuscles ;  or  it  may  be  produced  by  a  weakness  of  the  vessels, 
or  by  an  obstruction;  but  it  always  has  congestion  as  its  immedi- 
ate antecedent. 


SEROUS    EFFUSION.  35 

Congestion  is  divided  into  active  and  passive,  or,  as  some  prefer, 
into  active,  passive,  and  mechanical. 

Suppose,  then,  that  the  vis  a  tergo  (, whether  consisting  in  the 
heated  and  expanded  condition  of  the  blood  in  the  lungs,  or  in 
the  action  of  the  heart),  or  suppose,  that  some  abnormal  irritation 
of  the  arterial  muscular  coat,  or  various  influences  combined,  are 
hastening  the  current  through  the  arteries,  while,  from  the  capil- 
laries onward  through  the  veins,  it  is  not  hastened,  the  invariable 
effect  must  be  congestion.  This  is  sthenic  or  active  congestion. 

Again,  suppose  the  veins  to  be  weakened,  arid  the  circulation 
through  them  to  be  consequently  checked, — the  current  from  the 
heart  coming  on  with  its  normal  rapidity, — then,  of  course,  conges- 
tion must  follow  as  before.  This  is  asthenic  or  passive  congestion. 

I  am  of  the  opinion  that  a  weakened  condition  of  the  muscular 
coat  of  the  veins,  together  with  a  weakness  in  the  power  of  the 
valves,  is  not  imfrequently  the  principal  cause  of  congestion. 
The  veins  not  having  tonicity  enough  to  support  the  current,  are 
morbidly  relaxed;  and,  the  valves  not  affording  the  proper  resis- 
tance, the  power  of  gravitation,  when  the  position  of  the  patient 
favors,  occasions  congestion. 

Still,  again,  suppose  the  blood  to  be  impeded,  in  its  return  to 
the  heart,  by  some  obstruction  in  the  course  of  the  veins,  so  that 
it  accumulates  in  a  portion  of  the  venous  system.  This  is  what 
Dr.  Watson  calls  mechanical  congestion;  but  it  may,  with  equal 
propriety,  be  called  passive  congestion.  It  is  the  result,  not  of 
increased,  but  of  obstructed  and  diminished  action.  We  have  an 
instance  of  it,  in  the  case  of  cording  the  arm  for  venesection. 
The  veins,  lying  nearer  the  surface  than  the  arteries,  are  mechan- 
ically obstructed,  and  the  blood  accumulates. 


CHAPTER  IV. 

SEROUS    EFFUSION. 

There  are  two  methods  under  which  the  serum  of  the  blood 
is  separated  from  the  other  portions,  and  is  collected  either  in  are- 
olar  tissue  or  in  shut  sack.  The  one  of  these  methods  which  I 


36  THORACIC    DISEASES. 

call  secretion,  will  be  considered  in  another  connexion.  The 
other  which  is  effusion,  requires  to  be  illustrated  here.  The  for- 
mer supposes  an  active  condition  of  secreting  organs.  The  latter 
implies  merely  a  passive,  or  relaxed  and  over-distended  state  of  the 
coats  of  the  larger  vessels, — ordinarily,  if  not  always,  the  veins. 

Compress  any  of  the  veins,  as  when  a  ligature  is  applied  to  the 
arm  preparatory  to  venesection,  and  let  the  compression  remain 
for  a  considerable  time  ; — oedema  of  the  surrounding  areolar  tissue 
will  invariably  take  place.  That  is,  the  serum  of  the  blood  will 
be  effused  or  passed  through  the  coats  of  the  veins.  The  fibrine 
and  the  red  corpuscles  being  vitally  and  chemically  organized, 
of  course,  their  proximate  elements  occupy  an  appreciable  space ; 
whereas  the  serum,  being  without  any  distinct  traces  of  organiza- 
tion, is  made  up  of  elements  in  a  different  condition.  These 
elements  will  readily  pass  through  interstices  too  small  to  allow 
the  passage  of  the  fibrine  or  of  the  red  corpuscles.  In  all  cases, 
in  which  the  course  of  the  blood  in  the  veins  is  materially  ob- 
structed, for  any  length  of  time,  the  consequence  is  a  serous 
effusion.  Hence,  according  to  the  position  of  the  obstruction, 
arise  different  forms  of  dropsy. 

It  has  been  supposed,  that  capillary  obstruction,  holding  back 
the  arterial  current  and  causing  over-distention  in  the  arteries, 
sometimes,  produces  effusion  through  the  arterial  coats.  In  re- 
gard to  the  systemic  circulation,  I  think  this  is  not  so.  Cer- 
tain I  am,  that  in  general,  serous  effusion  takes  place  from  the 
venous,  and  not  from  the  arterial  system ;  and  it  would  seem  to  be 
owing  to  the  fact,  that  venous  blood  contains  a  less  proportion  of 
fibrine  than  arterial,  and,  consequently,  has  a  less  amount  of  vi- 
tality. 

Two  considerations  favor  this  supposition.  The  first  is  this. 
The  circumstances  of  the  lungs  are  peculiar.  The  pulmonary 
arteries  circulate  the  purple  or  venous  blood;  and,  when,  in  pneu- 
monitis,  there  is  an  obstruction  of  the  capillaries  by  the  inflamma- 
tion, besides  the  blood  effused  at  the  capillaries,  there  is,  also,  a 
degree  of  serous  effusion.  It  would  seem,  that  this  takes  place, 
through  the  pulmonary  arteries,  from  the  blood  which  has  not  yet 
acquired  the  arterial  character,  and  that  it  is  owing  to  the  dimin- 
ished amount  of  vitality  in  the  purple  blood. 


THE  RKPARATIVE  PROCESS.  61 

The  other  consideration  is  the  effect  of  repeated  acts  of  vene- 
section, or  of  hemorrhage  from  an  accidental  cause.  As  the  blood 
loses  its  proportion,  not  merely  of  red  corpuscles,  but  finally-  of 
fibrine,  and  becomes  more  serous,  a  dropsical  effusion  sets  in  and 
increases. 


CHAPTER  V. 

THE    REPARATIVE    PROCESS- 

Those  who  embrace  the  notions  of  Hunter,  that  inflammation 
is  a  recuperative,  and  not  a  morbid  action,  seem  to  confound  togeth- 
er two  processes,  which  are  almost  as  unlike  each  other,  as  the 
hardening  of  clay  by  the  presence  of  heat,  and  the  hardening  of 
water  by  the  diminution  of  heat.  Not  only,  indeed,  are  the  two 
processes  very  dissimilar,  but  any  considerable  amount  of  inflam- 
mation, in  any  wound,  will,  at  any  time,  utterly  prevent  the  pro- 
cess of  reparation.  It  is  probable,  however,  that  the  frequently 
close  succession  of  the  one  process  to  the  other  has  aided  in  be- 
traying pathologists  into  an  important  error  in  regard  to  the  nature 
of  inflammation,  and  in  giving  rise  to  such  language  as  "  wounds 
uniting  by  adhesive  inflammation," — "  granulations  formed  under 
the  influence  of  a  healthy  inflammation," — and  the  like. 

The  truth  is,  the  reparative  process  is  entirely  distinct  from 
that  of  inflammation,  and,  in  almost  every  particular,  unlike  it. 
In  the  former,  there  is  nothing  of  the  redness,  swelling,  pain,  or 
heat  which  characterize  inflammation.  There  is  not,  to  any  ex- 
tent, a  morbidly  relaxed  and  over-distended  condition  of  the  capil- 
lary vessels ;  nor  is  there  an  effusion  or  extravasation  of  blood  into 
the  circumjacent  tissue,  as  sometimes  occurs  in  inflammation. 
Indeed,  the  two  processes  have  scarcely  a  single  phenomenon  in 
common. 

The  reparative  process,  taking  place  after  a  lesion  has,  by  any 
means,  been  produced,  is  but  little  more  than  an  increased  and 
slightly  modified  condition  of  that  action  by  which  the  system  is 
being  constantly  repaired, — i.  e.,  by  which  the  place  of  effete 
matter  removed  is  supplied.  The  lesion  may  be  the  result  of  an 

31 97P1 


38  THORACIC    DISEASES. 

incision,  of  contusion,  of  inflammation  itself,  or  of  some  one  of 
various  other  means ;  but  the  process  of  cure  is  substantially  the 
same,  in  all  cases. 

This  process  of  repair  is  not  under  the  control  of  any  indepen- 
dent power,  that  is  properly  entitled  to  some  distinctive  name, 
such  as  vis  medicatrix  naturce,  vires  vitce,  or  the  recuperative 
power  of  nature.  The  process  is  simply  one  controlled  by  law, 
established  in  the  system  and  at  all  times  existing.  The  results, 
of  course,  diifer,  according  to  the  existence  of  different  conditions, 
— the  law  remaining  the  same.  Under  the  circumstances  of  ordi- 
nary decay,  the  function  of  nutrition  is  performed  at  such  a  rate 
as  just  to  meet  the  demands  of  the  waste.  When  that  same 
function  needs  to  be  executed  more  rapidly,  the  circumstances  are 
such  that  more  nervous  stimulus  is  afforded;  but  it  is  all  in  obedi- 
ence to  an  unchanged  law.  The  lesion,  through  the  afferent 
nerves  of  the  nutritive  branch  of  the  nervous  system,  impressing 
its  condition  upon  the  nervous  centres  of  that  branch,  the  increas- 
ed exciting  influence  returns  through  the  efferent  nerves  of  the 
same  branch,  and  more  rapid  nutrition  is  the  necessary  effect. 

It  is  by  this  reparative  process,  that  the  parts  of  a  wound,  being 
brought  together,  unite,  if  under  favorable  circumstances,  by 
what  is  called  adhesion,  or  union  by  the  first  intention;  if,  under 
other  circumstances,  generally  by  the  formation  and  appropriation 
of  interstitial  matter.  Dr.  Carpenter,  however,  considers  the  pro- 
cess to  take  place  in  three  different  modes;  and,  evidently,  there 
is,  occasionally,  a  modification  of  manner,  slightly  different  from 
the  two  now  named.  I  cannot,  however,  wholly  endorse  the 
views  of  Dr.  C.  According  to  him,  the  three  modes  are  as  follows. 

The  first  is  "the  adhesion  of  the  sides  of  a  wound  by  a  medi- 
um of  coagulable  lymph,  or  of  a  clot  of  blood."  The  second  is 
"reparation  without  any  medium  of  lymph  or  granulations, — the 
cavity  of  the  wound  being  filled  by  a  natural  process  of  growth 
from  its  walls."  The  third  is  "reparation  by  means  of  a  new, 
vascular,  and  organized  substance,  termed  granulations." 

By  the  first  of  these  modes  is  meant  to  be  designated  what  "  is 
ordinarily  termed  union  by  the  first  intention."  But,  in  this  mod- 
ification of  process,  no  "clot  of  blood"  performs  any  vital  part. 
Blood,  when  clotted,  becomes  dead  animal  matter,  and  can  never 


THE  REPARATIVE  PROCESS.  39 

be  again  applied  to  vital  purposes.  This  is  just  as  true,  when 
the  blood  remains  in  the  tissues  and  in  the  capillaries,  as  when 
drawn  into  a  vessel.  If,  by  coagulable  lymph,  however,  is  meant 
the  hyaline  fluid,  then  the  expression  contains  the  truth.  This 
fluid  is  employed  in  forming  cells  and  producing  the  adhesion  of 
the  sides  of  the  wound ;  but  the  term  is  a  bad  one,  as  it  suggests 
the  notion  of  coagulated  blood  or  a  clot;  and,  indeed,  seems  to 
have  been  used,  by  Dr.  C.,  as  synonymous  with  the  phrase,  "a 
clot  of  blood." 

The  process  of  union  by  the  first  intention  is  really  a  simple 
one.  In  the  first  place,  liquor  sanguinis  is  secreted  (,not  effused), 
on  the  edges  of  the  wound, — those  edges  being  placed  in  juxtapo- 
sition. This  fluid  and  the  red  corpuscles  compose  the  blood ;  but 
the  red  corpuscles  remain  in  the  circulating  current.  That  portion 
of  this  fluid  which  is  scarcely  vitalized,  is  composed  mainly  of  al- 
bumen and  water,  and  is  called  the  serum.  The  more  watery 
part  of  this  is  evaporated  or  absorbed.  The  other  probably  re- 
mains; and,  with  the  fibrine  (, containing  the  primary  granules), 
takes  on  a  smooth  and  glassy  appearance.  Hence,  the  whole  is 
called  the  hyaline  fluid.  It  is,  also,  termed  blastema  and  cyto- 
blastema;  because  it  is  "the  basis  of  every  forming  structure  of 
the  human  body;" — in  other  words,  because  it  contains  the  first 
buddings  or  cell-buddings  of  new  growths.  When  this  fluid  is 
examined  by  the  microscope,  it  is  seen  to  contain  regular,  though 
minute,  spheroidal  cells ;  besides  which,  there  are  innumerable 
graniform  bodies  of  still  smaller  size,  appearing  merely  as  specks 
or  dots  in  the  blastema,  and  these  latter  are  elementary  or  primary 
granules, — the  very  beginnings  of  the  spheroidal  cells.  These 
appearances,  the  fully  developed  cells,  especially,  have  sometimes 
been  called  exudation  corpuscles.  The  name,  however,  is  an  un- 
fortunate one,  as  they  are  entirely  distinct  from  the  red  corpuscles, 
and  must  not  be  confounded  with  the  latter. 

Though  the  hyaline  fluid  is  itself  vitally  organized,  in  a  de- 
gree, yet  it  is  only  the  granules  and  the  formations  from  them, 
which  exhibit  the  traces  of  full  or  perfect  organization.  Every 
fully  developed  cell  has  a  triple  organization, — a  nucleolus  or  nu- 
clcoli  (.for  there  are  sometimes  two  or  three  within  one  cell),  a 


40  THORACIC    DISEASES. 

nucleus,  and  a  cell-wall  or  investing  envelope.     These  nucleoli 
are  really  an  aggregation  of  the  primary  granules. 

As  the  reparative  process  advances,  these  nucleoli  multiply,  and 
the  blastema  assumes  a  greater  opacity.  Molecules  aggregate 
around  one  or  more  of  these  nucleoli,  and  a  nucleus  is  formed. 
To  complete  the  cell,  however,  a  transparent  and  most  delicate 
membrane,  composed  of  proteine,  invests  the  whole,  and  consti- 
tutes the  wall.  The  blastema,  in  which  the  cells  float  is  albumi- 
nous matter,  with  only  the  faintest  traces  of  organization,  while 
the  fluid  contents  of  the  cell — the  medium  interposed  between 
the  nucleus  and  the  cell-wall — are  more  distinctly  fibrinized — 
being  attracted  within,  and,  in  the  process,  becoming  changed,  by 
the  vital  power  of  the  nucleus. 

The  nuclei,  becoming  the  parents  of  other  cells,  are  sometimes 
called  cytoblasts  or  cell-germs, — the  name  being  designed  to  indi- 
cate the  peculiar  function.  A  nucleus,  with  its  nucleolus  or  nu- 
cleoli, being  an  aggregation  of  granules,  each  one  of  which  is 
capable  of  being  developed  into  an  independent  cell,  new  cells 
may  be  completely  formed  within  a  primitive  one ;  or  the  primi- 
tive one  may  rupture  and  scatter  its  contents  into  the  surrounding 
blastema,  where  they,  in  turn,  may  assume  the  characteristic  triple 
organization, — producing  and  reproducing  new  cells,  indefinitely. 
Again,  cells  may  form,  in  the  blastema,  in  an  isolated  manner  from 
pre-existing  granules,  when  these  granules  are  in  contact  with 
living  tissues.  In  this  case,  each  granule  attracts  to  itself,  assimi- 
lates, and  organizes  a  portion  of  the  nutritious  fluid,  forming  it 
into  the  cell- wall  and  the  contents  of  the  cell. 

Cells,  as  first  found,  are  generally  spheroidal  in  shape;  but  they 
become  variously  modified,  in  forming  the  several  different  tissues. 
Sometimes  they  become  elongated,  sometimes  flattened,  fusiform, 
prismatic,  polyhedral,  or  caudate,  according  to  the  purpose  to 
which  they  are  devoted.  In  the  formation  of  new  tissue,  the 
cells  arrange  themselves  in  longitudinal  lines,  the  proximate  surfa- 
ces of  the  cell-walls  disappear,  and  a  tubular  cavity  is  made.  In 
this  way,  according  to  the  form  which  the  cells  assume,  and  the 
matter  with  which  they  become  filled,  the  muscular,  the  nervous 
the  osseous,  and  all  the  various  tissues  are  formed. 

There  are  other  modifications  of  circumstances  under  which 


THE  REPARATIVE  PROCESS.  41 

cells  appear.  Some  float  in  the  blastema,  independently  of  each 
other;  and,  hence,  arc  called  isolated  cells.  From  their  ephemer- 
al nature,  also,  they  are  called  transition  cells,  in  opposition  to 
those  which  form  an  integral  part  of  the  more  permanent  tissues, 
and  are,  therefore,  called  permanent  cells.  The  transition  cells 
have  their  own  purposes  to  serve.  For  instance,  they  are  em- 
ployed in  the  formation  of  the  epidermis,  the  nails,  the  epithelial 
mucous  membrane,  and,  in  general,  those  tissues  which  are  rapid- 
ly thrown  off  and  formed  anew.  Those  of  the  epidermis 
and  the  epithelium  seem  to  originate  in  molecular  granules, 
which  are  diffused  through  the  substance  of  the  basement  mem- 
brane. 

While  cells  are  developed  under  such  varieties  of  circumstances 
as  have  now  been  considered,  it  is,  to  my  own  mind,  sufficiently 
clear,  that  elementary  granules  exist  in  the  current  which  circu- 
lates in  the  lymphatic  system,  and  which  is  composed  of  lymph 
and  chyle  united  ;  and  these  elementary  granules,  as  well  as  the 
more  organized  portions  of  cells,  are  centres  or  poles,  from  which 
emanate  ncrvo-vital  influences,  to  carry  on  the  purposes  of  vitali- 
ty and  organization. 

To  return  now  to  the  case  of  an  incised  wound,  suppose  new 
cells,  as  they  are  formed,  to  arrange  themselves  in  order  one  upon 
another ; — suppose  this  process  to  commence  on  both  edges  of  the 
wound  simultaneously ; — and  suppose,  moreover,  that  those  edges 
are  in  juxta-position,  that  is,  are  as  nearly  in  contact  as  they  can 
be  conveniently  arranged.  No  sooner  does  the  longitudinal  ar- 
rangement of  cells  commence  from  each  edge,  than  the  outermost 
ones  meet,  and,  by  assimilating  a  portion  of  the  blastema,  unite, 
the  circulation  becomes  established,  nervous  influences  pass  from 
one  edge  to  the  other,  and  the  wound  is  healed.  This  is  the  sim- 
ple process  of  union  by  the  first  intention.  A  clot  of  blood,  in 
this  case,  can  do  no  more  than  to  keep  off  the  atmosphere  and 
other  irritating  agencies  from  without,  by  filling  the  interstices, 
where  the  parts  are  not  entirely  in  apposition.  It  is,  from  this 
kind  of  protection,  that  benefit  is  secured,  by  dressing  a  wound, 
in  the  blood,  as  the  phrase  is.  The  incised  edges,  by  being  im- 
mediately shielded  from  deadening  influences,  remain  in  a  condi- 
tion to  take  on  the  healing  process.  Of  course,  as  soon  as  the 
(i 


42 


THORACIC    DISEASES. 


cells,  accumulating  upon  one  another,  meet  from  the  two  edges, 
the  parts  unite  and  the  wound  is  healed. 

The  SECOND  MODE  in  which  Dr.  Carpenter  considers  the  repara- 
tive  process  to  be  effected,  Dr.  Macartney  c;»]ls  the  modeling 
process.  In  this  case,  "  the  surfaces  of  the  wound  do  not "  im- 
mediately "  unite  by  vascular  connexion."  The  edges  take  on  a 
smooth  and  rather  red  appearance,  much  like  mucous  membrane. 
They  seem  also  to  be  slightly  moistened  with  a  thin  fluid.  This 
is  usually  considered  as  a  case  of  natural  growth  from  the  walls 
of  the  wound,  till  the  parts  finally  become  united.  This  mode  of 
union  may,  by  care,  be  effected,  where  otherwise  the  process  would 
be  accompanied  by  granulations  and  suppuration.  The  means  to 
be  employed  are  the  exclusion  of  air  and  of  other  irritating  causes. 

Now,  in  my  view,  the  difference  between  this  mode  and  that 
of  union  by  the  first  intention  is  exceedingly  slight.  The  parts 
not  being  in  juxta-position,  there  must  be  an  evident  accumula- 
tion of  cells  one  upon  another.  Transition  cells  form  an  epithel- 
ial covering  to  the  growth  from  permanent  cells  ;  the  accumulation 
continues ;  and,  when  the  parts  meet,  the  epithelium  disappears, 
and  union  is  effected.  The  increased  accumulation  of  cells,  and 
the  existence  of  epithelium,  during  the  growth,  constitute  essen- 
tially the  whole  difference  between  this  mode  and  that  first  con- 
sidered. Indeed,  when  a  wound  is  said  to  unite  by  the  first  in- 
tention, often  interstices  are  first  filled  by  coagulated  blood,  or  are, 
in  some  way,  protected ;  and  the  case  is,  in  part,  as  really  one  of  the 
modeling  process,  as  any  which  are  ordinarily  regarded  as  such. 

Dr.  Carpenter's  third  mode  of  reparation  is  one  in  which  gran- 
ulations are  employed.  These  are  formed  under  the  unfavorable 
circumstances  of  irritation  or  continued  inflammation.  The  gran- 
ulation structure  is  a  special  one  formed  for  a  temporary  purpose. 
It  is  endowed  with  higher  vascularity.  and  a  more  rapid  power  of 
growth,  than  is  possessed  by  any  modification  of  ordinary  tissue; 
but  it  is  very  easily  destroyed,  by  injury  or  by  increased  inflam- 
mation. 

The  formation  and  the  effect  of  the  granulation  structure  prove, 
that  parts,  previously  healthy,  are  disposed  to  heal,  in  spite  of 
many  impediments  thrown  in  their  way.  Here,  however,  there  is 
no  vis  medicairix  naturce,  in  the  sense  of  an  independent  power, 


THE    REPARATIVE    PROCESS.  43 

interposing,  just  at  this  juncture,  for  the  individual's  good.  An 
invariable  law  controls  the  process,  though  the  nature  of  that  law 
is  not  yet  fully  understood.  My  own  conviction  is,  that,  when 
granulations  are  formed,  the  capillary  vessels  in  connexion  with 
the  part  affected  are  always  abnormally  enlarged,  either  by  irri- 
tating causes  from  without,  or  by  the  latter  stage  of  inflammation 
within.  The  chemical  influence  of  the  atmosphere  tends  to 
weaken  innervatiori,  and  thereby  to  relax  and  over-distend  the  coats 
of  the  capillaries.  In  the  passive  stage  of  inflammation,  the  ves- 
sels are  yet  over-distended,  though  the  counteracting  effect  of  the 
active  period  of  the  disease  has  essentially  subsided.  In  this  case, 
there  is  a  secretion  of  liquor  sanguinis,  but  it  is  modified  by  the 
existence  of  the  white  globules,  or  by  a  chemically  changed  con- 
dition of  the  blood.  Either  these  globules  actually  pass  through 
the  walls  of  the  over-distended  capillaries  to  form  crude  cells  with- 
out; or  what  is  more  probable,  the  primary  granules,  perhaps,  in 
a  modified  condition,  pass  through  the  vessels,  with  liquor  san- 
guinis of  a  modified  character ;  so  that  the  hyaline  fluid  without 
differs  from  what  is  normal,  and  from  it  a  different  structure  is 
consequently  elaborated.  In  the  case  of  granulations  from  exter- 
nal irritation,  the  modification  of  the  hyaline  fluid  is  evidently  the 
result  of  a  change  produced  either  directly  on  the  surface,  or  at 
the  secreting  points  of  the  capillaries.  This  irritation  does  not, 
like  inflammation,  produce  coagulation  in  the  capillaries.  Still,  it 
may  extend  its  effect  somewhat  beneath  the  surface,  so  as  to  form 
in  the  vessels,  a  proteirie  compound,  like  that  of  inflammation. 

In  the  hyaline  fluid,  as  granulations  are  forming,  there  are  seen 
extremely  minute  molecules,  composed  probably  of  fatty  matter, 
and  granules  measuring  from  one  twelve  thousandth  to  one  eight 
thousandth  of  an  inch  in  diameter,  consisting  essentially  of  the 
deutoxide  of  proteine  with  a  central  molecule  of  fat ;  also,  still 
larger  bodies,  exudation  corpuscles,  compound  granules,  or  cells, 
measuring  from  one  six  thousandth  to  one  seven  hundreth  of  an 
inch  in  diameter.  Basides  these  bodies,  there  are  extremely  fine, 
interlaced,  and  decussating  fibrils  much  like  those  seen  in  the  buffy 
coat  of  the  blood.  . 

The  kind  of  action,  then,  in  the  formation  of  granulations  is 
essentially  the  same,  as  that  in  union  by  the  first  intention,  or  in 


44  THORACIC    DISEASES. 

the  modeling  process.  Liquor  sanguinis,  modified,  is  secreted  ; 
and,  the  serum  or  its  watery  portion  being  disposed  of,  the  blaste- 
ma remains  pregnant  with  cells,  which  arrange  themselves  one 
upon  another,  presenting  the  appearance  which  has  been  undesira- 
bly called  that  of  exudation  corpuscles.  Over  all,  an  imperfect  epi- 
thelium is  formed,  probably  by  means  of  transition  cells.  In  this 
process,  as  in  the  more  perfect  one  already  described,  a  portion  of 
the  blastema  is  assimilated  and  more  fully  organized.  New  lay- 
ers are  developed,  and  the  void  is,  at  length,  filled. 

The  effect  of  any  external  irritating  influences  and  of  any  re- 
maining inflammation  having  passed,  the  usual  reparative  process 
goes  forward.  In  the  ordinary  nutrition  of  the  system,  effete  mat- 
ter is  thrown  off,  as  new  matter  is  deposited  :  and  so,  in  this  case, 
the  granulation  deposit  is  separated  and  absorbed,  as  the  new  and 
more  permanent  tissue  is  formed.  One  peculiarity  of  appearance, 
however,  remains,  after  a  wound  has  been  permanently  healed. 
The  granulation  structure,  which  is  removed  by  interstitial  absorp- 
tion, being  less  dense  than  the  more  permanent  tissue,  the  portions 
removed,  in  a  given  time,  occupy  more  space  than  those  which 
are  deposited.  The  consequence  is,  that,  after  the  work  is  com- 
pleted, the  paTts  are  left  contracted  and  a  cicatrix  shows  itself. 

Those  fungous  growths  which  are  commonly  called  proud  flesh, 
are  the  result  of  an  excessive  granulating  process.  That  they  oc- 
cur in  accordance  with  fixed  law,  and  under  modified  nervous  ac- 
tion, cannot  be  questioned,  though  we  cannot  trace  all  the  work- 
ings of  vitality  in  such  exuberant  formations. 

In  every  case  of  lesion,  in  whatever  way  created,  the  healthy 
condition  of  the  part  must  be  restored  by  the  reparative  process, 
in  some  one  of  the  modes  now  considered.  If  the  lesion  has 
been  produced  by  inflammation,  and  that  under  ordinary  circum- 
stances, as  in  the  muscular  and  areolar  tissues  lying  near  the  sur- 
face,— and  if,  at  the  same  time,  there  is  no  appreciable  destruction 
of  the  tissues,  the  reparative  process  has  comparatively  little  more 
to  do  than  it  has  in  serving  the  ordinary  'purposes  of  nutrition. 
When,  however,  the  inflammation  is  upon  a  serous  tissue,  there  is 
frequently  a  too  luxuriant  growth,  ordinarily  termed  false  or  exuda- 
tion membrane.  In  this  case,  the  hyaline  fluid  is  copiously  depos- 
ited in  much  the  same  manner  as  in  superficial  fungous  growths. 


THE    RED    CORPUSCLES.  45 

When  fungous  growths  and  exudation  membranes  give  place  to  a 
normal  condition  of  the  parts,  the  process  is  evidently  that  of  ab- 
sorption, just  as  ordinary  granulations  are  absorbed,  when  the  more 
permanent  structure  is  formed. 

It  is  proper  here  to  remark,  that  the  plastic  power  of  the  blood, 
that  is,  its  capability  of  being  transformed  into  organized  tissue,  is 
in  proportion  to  the  quantity  of  fibrine  which  it  contains.  Though 
the  chyle  exhibits  faint  traces  of  fibririization,  immediately  on 
passing  the  lacteals,  and  though  the  current  of  chyle  and  lymph 
united  partakes  more  and  more  of  this  character,  till  it  reaches  the 
thoracic  duct ;  yet,  in  the  blood,  the  proportion  of  fibrine  is  greater 
than  in  any  part  of  the  lymphatic  current,  and  that  notwithstand- 
ing the  constant  withdrawal  of  it  from  the  blood  for  the  purposes 
of  nutrition.  From  this  fact  it  is  sufficiently  evident,  that  fibrine  is 
elaborated,  partly,  by  some  agency  in  the  blood  vessels.  As  to 
Avhat  that  agency  is  I  have  already  given  my  opinion. 

When  blood  is  drawn  from  the  body,  and  its  fibrine  is  coagula- 
ted in  a  vessel,  that  coagulated  fibrine  has  something  like  a  rudi- 
mentary appearance  of  organization.  It  contains  what  appear 
much  like  organic  germs.  This  particular  resemblance  to  the 
change  effected  by  the  conversion  of  the  hyaline  fluid  into  solid 
tissues,  has  probably  been  principally  concerned  in  giving  rise  to 
confused  notions  and  uses  of  terms,  in  speaking  of  the  reparative 
process.  These  organic  germs,  or  corpuscles,  as  they  have  been 
called,  which  appear  in  a  clot  of  fibrine,  seem  to  be  formed  by 
means  of  an  electric  influence  derived  from  the  atmosphere.  But 
electricity  is  not  nervo-vital  fluid,  and,  therefore,  cannot  do  the 
full  work  of  that  fluid.  It,  to  some  extent,  imitates,  but  it  cannot 
become  vital  action. 


CHAPTER  VI. 

THE    RED    CORPUSCLES. 

'•  The  human  blood  corpuscles  or  red  globules"  says  Dr.  Mor- 
ton, "are  flattened  circular  discs,  with  a  central  concavity  or  de- 
pression on  each  surface,  which,  in  some  respects,  gives  them  an 


46  THORACIC    DISEASES. 

annular  appearance.  They  vary  between  the  300th  and  the  400th 
of  a  line  in  diameter,  and  their  thickness  is  about  one  fourth  of 
that  measure.  Each  corpuscle  is  a  cell,  of  which  the  envelope  is 
elastic,  homogeneous,  pellucid,  and  colorless;  and  the  contents  are 
of  a  more  or  less  deeply  red  color.  They  are,  however,  destitute  of 
distinct  nuclei, — the  dark  spot  which  is  seen  in  their  centre  being 
merely  an  effect  of  refraction,  in  consequence  of  the  double  con- 
cave form  of  the  disc.  But,  since  the  corpuscles  of  the  lower  an- 
imals are  distinctly  nucleated,  some  physiologists  insist,  that  the 
nucleus  exists  also  in  the  blood  of  mammiferse,  although  it  has 
hitherto  eluded  positive  demonstration." 

"The  vesicular  envelopes  of  the  blood  discs  have  been  sup- 
posed to  be  analogous  in  character  to  fibrine,  being  extremely  del- 
icate, transparent,  and  highly  elastic  membranes." 

"  The  contents  of  the  capsule  consist  of  two  different  substan- 
ces, called  heematine"  or  hcematocine.  "and  globuline." 

"  HcBinatine  or  hcemalodne  is  the  compound  that  fills  and  forms," 
with  globuline,  "the  substance  of  the  corpuscle,  and  gives  it  its 
characteristic  color.  When  the  coloring  matter  is  separated  from 
the  other  constituents,  it  appears  as  a  dark  brown  substance,  inso- 
luble in  water,  ether,  acids,  or  alkalies,  or  in  alcohol  alone,  but 
dissolves  in  alcohol  with  the  addition  of  sulphuric  acid  or  ammo- 
nia. This  solution  has  also  a  dark  color,  and  possesses  all  the 
properties  of  the  coloring  matter  of  venous  blood.  It  contains  a 
considerable  proportion  of  peroxide  of  iron ;  but  Scherer  has 
proved,  contrary  to  the  received  opinion,  that  the  coloring  matter 
is  not  derived  altogether  from  the  iron,  because,  when  the  latter 
is  wholly  separated  from  the  hasmatirie,  a  deep-red  coloring  mat- 
ter still  remains." 

Kirkes  and  Paget,  however,  say  of  it,  that,  as  ordinarily  ob- 
tained, "  it  is  soluble  in  water,  by  which  it  may,  with  the  globu- 
line, be  washed  out  of  the  blood  corpuscles;  and  from  this  solu- 
tion it  is  precipitated,  by  most  metallic  salts  and  by  concentrated 
acids.  In  the  living  or  recent  state  of  the  blood  corpuscles,  the 
heematine  is  confined  within  their  cell-walls,  and  appears  to  be  in- 
soluble in  the  serum ;  but,  when  the  blood  begins  to  decompose, 
and  the  cell-walls,  losing  their  texture,  permit  the  outward  pas- 
sage of  their  contents,  both  the  hsematine  and  the  globuline  are  dis- 


THE    RED    CORPUSCLES.  47 

solved  in  the  serum  which  thus  becomes  blood-colored,  and  may 
impart  its  tinge  to  the  surrounding  parts.  In  the  purest  state  in 
which  it  can  be  obtained,  it  is  so  far  changed  as  to  be  insoluble 
in  water,  of  a  deep  blackish-brown  color,  and  not  liable  to  change 
of  color  on  exposure  to  gases.  Boiling  alcohol  will  dissolve 
small  quantities  of  it,  and  it  is  freely  soluble  in  alcohol  acidula- 
ted with  sulphuric,  hydrochloric,  or  nitric  acid,  and  in  weak  so- 
lutions of  potash,  soda,  or  ammonia." 

"The  presence  of  so  large  a  proportion  of  iron,  constitutes  a 
peculiar  feature  in  hasmatine.  The  mode  in  which  the  metal  ex- 
ists in  it  has  been  much  discussed.  By  some  it  is  supposed  to  be 
in  the  form  of  an  acid,  or  a  salt,  or  in  the  form  of  peroxide  in 
arterial  blood,  and  carbonate  of  the  protoxide  of  iron  in  venous 
blood.  The  greater  probability  is,  that  the  iron  is  combined,  as 
an  element,  with  the  four  essential  elements,  in  the  same  manner 
as,  it  is  held,  sulphur  is  combined  with  them  in  albumen,  fibrine, 
cystic  oxide,  &c." 

"  It  is  very  doubtful,  whether  the  rapid  change  of  color,  which 
is  effected  in  respiration  and  on  the  contact  of  various  gases,  can 
be  referred  to  any  chemical  changes  whatever,  in  the  hosmatine. 
Much  more  probably  it  is  due  to  changes  in  the  form  of  the  blood 
corpuscles  and  their  consequently  different  modes  of  reflecting 
and  transmitting  light.  Saline  solutions,  if  denser  than  the  liquor 
sanguinis,  contract  and  shrivel  up  the  corpuscles,  making  them 
deeply  bi-concave ;  and  distilled  water  has  the  contrary  effect, 
swelling  out  the  corpuscles,  and  making  them  thickly  bi-convex 
or  spherical.  Changes  corresponding  with  these  are  produced,  by 
the  contact  of  oxygen  and  of  carbonic  acid  with  the  corpuscles ; 
— the  former  contracting  them,  and  making  their  cell-membranes 
thick  and  granular, — the  latter  dilating  them,  and  thinning  and 
finally  dissolving  their  cell-walls.  Herein,  then,  is  a  sufficient  ex- 
planation of  the  changes  that  the  corpuscles  undergo,  without  sup- 
posing any  immediate  chemical  alteration  in  the  hasmatine." 

"  Globuline"  says  Dr.  Morton,  "  is  obtained  from  the  capsule  of 
the  red  corpuscles  and  is  their  component  element.  It  is  regarded, 
by  the  chemists  as  a  proteine  compound,  closely  allied  to  albumen, 
— from  which  it  differs,  however,  in  being  soluble  in  serum  and 
in  coagulating  in  a  granular  form,  unlike  the  residue  from  albu- 


48  THORACIC    DISEASES. 

men.  Henle  suggests,  that  globuline  is  albumen,  modified  by 
combination  with  the  substance  of  the  disc-envelopes.  The  glob- 
uline and  hsematine  combined  constitute  the  admitted  contents  of 
the  globules,  and  are  called  the  en/or." 

Kirkes  and  Paget  say,  that  "  globuline  appears  to  be  a  proteine 
compound.  According  to  Simon,  it  bears  some  resemblance  to 
caseine,  on  which  account  he  named  it  caseine  of  blood  :  but 
Liebig  and  others  regard  it  as  more  similar  to  albumen.  It  is  so- 
luble in  water,  and  its  solution,  when  heated,  forms  a  granular 
coagulum." 

What  I  have  now  quoted  refers  to  the  chemical  character  of 
the  corpuscles.  In  regard  to  their  origin,  Dr.  Morton  says,  "The 
human  blood  corpuscles  are,  by  many  physiologists,  even  by  those 
who  deny  their  nucleated  character,  regarded  as  cells,  capable  of 
reproduction  in  the  manner  of  the  cells  of  other  tissues."  In 
thus  speaking  of  "other  tissues,"  the  doctor  seems  to  regard  the 
blood  itself  as  a  tissue.  He  continues, — "  This  process,  accord- 
ing to  the  latest  microscopists,  is  shown  in  the  following  manner. 
First,  radiating  lines  are  seen  to  pass  from  the  centre  to  the 
periphery,  dividing  the  disc  into  several  segments,  usually  six  in 
number:  and  these  parts  become  gradually  isolated  from  the  par- 
ent corpuscle,  and  constitute  as  many  new  and  independent  cells. 
It  is.  in  this  manner,  that  the  red  corpuscles  are  rapidly  generated 
by  a  power  of  self-production  within  themselves, — which  is  in- 
creased or  retarded,  however,  by  various  circumstances." 

Thus  much,  in  regard  to  the  nature  of  the  red  corpuscles, 
being  understood,  the  grand  but  hitherto  unsettled  question  arises, 
What  is  their  function?  Different  conjectures  have  been  formed. 
One  is,  that  they  convert  the  albumen  of  the  blood  into  fibrine. 
But,  to  this  view,  there  are  serious  objections.  Fibrine  is  exten- 
sively found  in  the  lymphatic  vessels,  and  yet  these  vessels  con- 
tain no  red  corpuscles.  Again,  invertebrate  animals  have  no  red 
globules  in  their  blood;  but  albumen,  with  them,  is  changed  into 
fibrine  as  readily  as  with  animals  having  red  blood. 

Another  conjecture  is,  that  the  red  corpuscles  are  "  carriers  of 
oxygen  to  the  various  tissues,  and  of  carbonic  acid  from  these  tis- 
sues to  the  lungs."  To  an  extent  this  is,  doubtless,  the  correct 
theory.  Experiments,  it  is  true.,  have  shown  very  clearly,  that  a 


THE    RED    CORPUSCLES.  49 

portion  of  the  oxygen  taken  into  the  lungs,  in  respiration,  is,  in 
those  organs,  united  with  carbon  which  is  in  the  blood,  there  to 
form  carbonic  acid.  So  far,  then,  as  the  oxygen  is  there  used,  it 
cannot  be  carried  through  the  circulation  by  the  corpuscles ;  and, 
so  far  as  carbonic  acid  is  formed  in  the  lungs,  it  cannot  be  brought 
to  the  lungs,  by  the  corpuscles. 

Still,  it  is  certain,  that  oxidation  takes  place  in  the  capillaries, 
throughout  the  system  ;  and  the  oxygen  employed  must  be  trans- 
mitted through  the  arteries  by  the  red  corpuscles,  while  the  car- 
bonic acid  created  at  the  capillaries  must  be  returned  through  the 
veins,  by  the  same  vehicles. 

The  most  directly  vital  office  of  the  red  corpuscles,  however, 
is  the  reception  and  transmission  of  electricity.  Whether  this  is 
attracted  from  the  inspired  air,  by  the  power  of  the  iron  contained 
in  them,  or  is  generated  in  connexion  with  the  oxidizing  process,  is 
yet  a  matter  of  doubt.  Be  that  as  it  may,  electricity  being  found 
in  connexion  with  the  corpuscles,  they  then,  through  afferent 
nerves  connected  with  the  serous  coat  of  the  blood-vessels,  con- 
vey that  electricity  to  the  nervous  centres  or  ganglia  of  the  sever- 
al nervous  systems.  At  these  ganglia,  the  electric  fluid  is  con- 
verted into  nervo-vital  fluid,  and  is  then  sent,  by  efferent  nerves, 
to  every  part  of  the  body.  Of  course,  a  portion  of  this  nervo- 
vital  fluid,  sent  from  the  ganglia  of  the  nutritive  system,  passes  to 
the  lymphatic  glands,  where  the  elementary  granules  of  the  cells 
have  their  origin,  there  to  form  these  granules, — as  well  as  to  the 
lymphatic  ducts  generally,  to  elaborate  fibrine  from  the  albumen 
of  the  lymph  and  chyle. 

The  shut  sacs  of  the  body,  generally,  are  lined  with  serous 
tissue  and  become  the  repositories  of  nervo-vital  fluid.  Hence, 
when  any  portion  of  that  tissue  is  inflamed,"  the  excited  nervous 
action,  circulating  an  increased  quantity  of  nervo-vital  fluid,  gives 
a  full  and  hard  pulse  ;  whereas  excited  nervous  action  on  mucous 
tissues,  passing  off  this  same  fluid  too  rapidly  to  the  atmosphere 
around,  creates  a  rapid  and  feeble  pulse. 

In  regard  to  the  white  globules  or  lymph  corpuscles,  which  are 
found  m  the  blood,  they  are  evidently  allied  in  character  to  the 
primary  cells,  which  repair  the  system  as  already  explained. 

Experiments  have  conclusively  shown,  that  repeated  venesec- 
7 


50  THORACIC    DISEASES. 

tions  reduce  the  quantity  of  red  corpuscles  and  of  albumen  in  the 
blood,  but  do  not  readily  affect  appreciably  the  amount  of  fibrine. 
The  explanation  of  this  truth  is  as  follows.  As  the  veins  are 
being  partially  emptied  of  their  contents,  they  collapse  upon  the 
remaining  current,  for  the  time  being ;  but  they  are  soon  filled 
again  by  the  absorption  of  a  watery  liquid  from  the  system.  The 
blood  abstracted  diminishes  proportionally  the  corpuscles,  the  al- 
bumen, and  the  fibrine ;  but  the  last  being  elaborated,  to  a  con- 
siderable extent,  in  the  lymphatic  vessels,  those  vessels,  almost 
immediately,  supply  a  quantity  nearly  equivalent  to  what  has 
been  removed.  The  red  corpuscles  elaborated  in  the  blood-ves- 
sels, and  the  albumen  of  the  serum  which  escapes  the  fibrinizing 
power,  are  not  subjected  to  influences  to  give  them  so  rapid  an 
accumulation. 


CHAPTER  VII. 

THE    FORMATION    OF    PUS. 

That  pus  is  very  commonly  formed,  in  connexion  with  the  pro- 
duction of  granulations  is  admitted  by  all;  but  whether  it  is  al- 
ways so  formed, — what  its  precise  nature  is, — and  by  what  means 
it  is  created,  are  questions  which,  till  of  late,  have  been  quite  un- 
settled. 

Pus  appears  under  various  modifications,  and  circumstances  will 
rapidly  change  its  qualities.  Well-formed  pus  is  an  opaque, 
smooth,  yellowish  fluid,  without  scent,  arid  having  nearly  the 
consistence  of  cream.  By  the  old  writers,  it  was  spoken  of  as 
laudable  pus ;  and  it  is  still  quite  frequently  called  healthy  pus. 
The  latter  epithets,  laudable  and  healthy,  are  unfortunate  ones. 
They  were  selected  when  the  most  incorrect  and  absurd  notions 
prevailed  in  regard  to  the  reparative  process.  A  degree  of  inflam- 
mation was  considered  benign  in  its  influence,  and  as  constituting, 
in  itself,  the  process  of  healing.  Well-formed  pus  always  indica- 
ted, that,  to  some  extent,  reparation  was  going  on.  So,  as  it  would 
seem,  it  was  taken  as  evidence  of  a  very  laudable  trait  in  the  gov- 
ernment of  that  superintending  power,  the  vis  medicatrix  natures  ; 


THE    FORMATION    OF    PUS.  5.1 

or  as  evidence,  that  healthy  inflammation  was  restoring  the  part 
diseased. 

Well-formed  pus  consists  of  yellowish  glohules,  diffused  through 
a  thin  fluid,  which  somewhat  resembles  the  serum  of  the  blood. 
"If  six  or  eight  ounces  of  good  pus  be  suffered  to  stand  in  a 
phial,  it  will  separate  into  two  portions.  A  yellowish  matter  will 
sink  to  the  bottom,  and  there  will  be  a  slightly  yellow,  clear,  su- 
pernatant fluid,  like  oil  in  appearance,  but  not  greasy  to  the  touch." 
The  sediment  consists  of  the  globules ;  and,  by  some,  they  have 
been  regarded  as  the  blood  corpuscles,  deprived  of  their  coloring 
matter,  and  modified  in  form.  To  this  view,  however,  there  are, 
at  least,  two  objections.  The  most  prevalent  opinion  of  physiol- 
ogists, at  present,  is  that  the  red  corpuscles  take  no  part  in  the  for- 
mative process;  and,  to  my  own  mind,  it  is  pretty  clear,  that  an 
entirely  different  office  is  assigned  them,  in  the  discharge  of  which 
they  do  not  leave  the  vascular  system,  and  cannot,  therefore,  ap- 
pear, with  the  granulations,  upon  any  surface.  The  other  objec- 
tion, alluded  to,  has  respect  to  the  rapidity  and  the  kind  of  change 
which  the  pus  globules  are  apt  to  undergo,  on  exposure  to  the 
air.  The  blood  corpuscles,  by  a  like  exposure,  coagulate  and 
form  a  clot ;  whereas  the  change  wrought  on  the  pus  globules,  is 
clearly  one  of  degeneracy  or  decay. 

But  pus  is  not  always  icell-formed.  Sometimes,  the  globules 
do  not  bear  a  due  proportion  to  the  watery  part ;  and  then  the  pus 
is  called  ichorous.  When  some  of  the  coloring  matter  of  the 
blood  happens  to  be  effused  or  extravasated  and  combined  with 
it,  it  is  spoken  of  as  sanious.  Mucus  may  be  mixed  with  it,  ren- 
dering it  viscid  and  slimy.  In  scrofulous  persons,  diseased  lymph 
may  blend  with  it,  and  give  it  flaky  and  curdled  appearance.  Oc- 
casionally, morbific  or  effete  matter,  in  the  system,  may  find  an 
outlet,  in  connexion  with  pus,  giving  it  a  fetid  odor.  When,  by 
a  breaking  down  of  tissues,  to  some  extent,  a  cavity  forms  abnor- 
mally in  the  system  for  the  reception  of  pus,  that  cavity  is  termed 
an  abscess ;  and  pus  from  abscesses  which  form  in  or  near  the  al- 
imentary canal,  is  peculiarly  liable  to  be  offensive  in  character. 
This  fact  is  probably  owing  to  the  tendency  of  the  system  to 
depuration  through  mucous  surfaces,  and  to  the  existence,  near 
those  surfaces,  of  matter  which  needs  to  be  eliminated. 


52  THORACIC    DISEASES. 

According  to  Lebert,  a  French  writer,  as  translated  by  Dr.  John 
A.  Svvett  of  New  York,  pus  globules  "are  alwiys  found  floating 
free  in  serum.  Their  mean  diameter  is  from  .01  to  .0125  of  a 
millimetre.  Their  shape  is  spherical.  Their  surface  is  slightly 
rough,  and  is  sometimes  covered  by  molecular  granules.  Their 
investing  membrane  is  more  or  less  transparent.  Their  contents 
are  liquid;  and  you  can  notice  in  them,  when  they  have  attained 
their  full  size,  one,  two,  three,  rarely  four  or  five  true  nuclei, 
whose  diameters  are  from  .0033  to  .005  of  a  millimetre,  and  in 
the  interior  of  which  a  nucleolus  can  often  be  detected. 

"  With  a  high  magnifying  power,  it  is  easy  to  discover  these 
nuclei  without  the  aid  of  any  chemical  reagent.  The  acetic  acid, 
however,  renders  them  more  distinct." 

Bearing  in  mind  that  the  pathological  and  surgical  writers,  gen- 
erally, have  not  distinguished  the  reparative  process  from  inflam- 
mation, we  shall  see,  by  their  writings,  that  they  considered  sup- 
puration to  be  a  process  necessarily  succeeding  the  formation  of 
new  tissue.  Dr.  John  Hunter  says,  "  The  new-formed  matter 
peculiar  to  suppuration  is  a  remove  farther  from  the  nature  of  the 
blood  than  the  matter  formed  by  adhesive  inflammation."  Dr. 
Thomas  Watson  says,  "  Pus  appears  to  be  poured  forth  or  secre- 
ted by  coagulable  lymph,  after  it  has  become  organized.  Its  for- 
mation seems  to  characterize  a  more  advanced  stage  of  inflamma- 
tion— to  denote  that  the  inflammation  has  been  pressed  a  little  be- 
yond the  adhesive  stage."  Dr.  S.  G.  Morton,  speaking  of  exu- 
dation corpuscles  arid  false  membranes,  says,  "By  tracing  the 
metamorphosis  a  single  step  further,  we  come  to  the  pus-globule." 
Dr.  Watson  does,  indeed,  say,  that,  "  in  the  natural  cavities  of 
the  body,  pus  seems,  sometimes,  to  mingle  gradually  with  the  se- 
rous effusion,  which  grows  turbid  and  whitish,  and  at  length  dis- 
tinctly assumes  a  punform  character."  But,  whether  he  intended 
this  remark  to  involve  an  exception  to  the  usual  manner  in  which 
pus  is  formed,  or  not,  it  is  clear  to  my  own  mind,  that,  in  fact,  he 
only  describes  a  case  in  which  the  reparative  process  goes  on 
slowly,  and  is,  at  the  same  time,  attended  with  but  a  slight  elab- 
oration of  pus.  Just  that  condition  of  things  must  be  induced, 
when  the  vital  or  recuperative  power  is  not  strong,  and  yet,  as  in 


THE    FORMATION    OF    PUS.  53 

a  shut  sac,  there  is  not  great  irritating  or  destructive  influence  at 
work  to  counteract  the  granulating  process. 

Let  us  suppose,  then,  that  suppuration  is,  ordinarily,  an  inter- 
ruption of  action  in  the  formation  of  granulations,  and  that  it  is 
never  a  direct  secretion  from  the  blood,  irrespective  of  tissue  form- 
ing or  formed.  Still,  another  question  arises  whether  false  mem- 
branes and  other  granulation  structures,  which  gradually  disap- 
pear during  the  existence  of  suppuration,  are  not  converted  into 
pus;  and  whether  even  old  tissues,  which  are  broken  down  in  the 
case  of  ulceration,  do  not  undergo  the  same  connection.  On  this 
question,  I  remark, — we  know,  that  often  granulations  are  removed 
by  interstitial  absorption,  when  there  is  no  suppuration ;  and  we 
know,  that,  in  ulceration,  matter  often  loses  its  vitality  and  breaks 
away  from  the  living  tissue,  just  as  in  a  simple  case  of  mortifica- 
tion. Antecedently,  therefore,  to  a  consideration  of  the  true  na- 
ture of  suppuration,  the  probabilities  are,  that  existing  tissues, 
whether  temporary  or  permanent,  are  always  removed  by  other 
means. 

But  what  is  the  true  nature  of  pus  ?  or  what  is  the  kind  of  ac- 
tion which  elaborates  it?  I  regard  suppuration  as  simply  a  degen- 
eration and  disintegration  of  the  organized  hyaline  fluid,  or  exu- 
dation corpuscles  just  as  they  are  being  deposited,  in  the  granula- 
ting process.  The  change  always  supposes  a  reduced  state  of  vi- 
tality in  these  corpuscles,  by  which  they,  in  a  measure,  lose  their 
power  of  organization,  and  become  a  kind  of  loose  aplastic  ma- 
terial. 

With  the  loss  of  vitality,  there  is,  also,  in  the  material  involved 
a  chemical  change,  which  consists,  mainly,  in  an  increased  oxid- 
ation of  that  material.  Well-formed,  pus  "is  composed  chem- 
ically of  water,  deutoxide  of  proteine  forming  the  cell-walls,  tri- 
toxide  of  proteine  and  albumen  in  solution,  fat,  osmazome,  and 
other  extractive  matters,  and  the  same  salts  as  those  in  the  blood." 
In  a  more  general  description  of  these,  however,  it  is  sufficient  to 
say,  that  the  more  solid  parts  are  deutoxide  of  proteine,  and  the 
more  dissolved  or  liquid  parts,  the  tritoxide. 

"  Microscopically,  pus  consists  of  a  limpid  serum,  and  very  nu- 
merous globules  of  pretty  regular  size  and  form,"  or  of  such  glob- 


54  THORACIC    DISEASES. 

ules  containing  such  serum.  "These  globules  have  much  resem- 
blance to  granular  cells  or  exudation  corpuscles ;  but  they  are 
larger,  and  are  more  distinctly  and  constantly  provided  with  a 
cell-wall  and  nucleus,  in  addition  to  granules  and  molecules."  In 
form,  they  are  generally  "spherical,"  though  "sometimes  irregu- 
larly rounded  or  oval.  Their  cell-wall  is  commonly  opaque  and 
somewhat  uneven,  from  being  studded  with  minute  granules." 
"Pus  globules  are,"  in  general,  "larger  than  exudation  corpuscles, 
even  exceeding  in  size  the  blood-discs.  According  to  Mr.  Addi- 
son,  they  measure  from  1-2000  to  1-1500  of  an  inch."  They  are 
evidently  a  modification  of  exudation  corpuscles. 

Physically,  pus  globules  are  without  great  power  of  cohesion. 
In  this  respect,  they  are  in  contrast,  with  the  primordial  cells  and 
the  red  corpuscles.  This  physical  effect,  however,  is,  doubtless, 
the  result  of  a  chemical  change. 

The  circumstances  which  give  rise  to  suppuration  are  mainly 
three;  an  increase  of  inflammation,  an  irritating  influence  of  air, 
and  a  certain  depraved  condition  of  the  blood.  It  is  easy  to  il- 
lustrate, at  least  in  part,  the  manner  in  which  these  circumstances 
produce  their  effect,  and  increase  the  oxidation  of  the  material 
concerned.  It  is,  however,  only  necessary  for  me  here  to  say, 
that  it  belongs  to  the  nature  of  inflammation  to  expose  the  affected 
part  to  the  reception  of  more  oxygen  ;  the  pressure  of  the  air 
does  the  same  directly,  and  likewise  increases  the  inflammation ; 
and  a  certain  depraved  condition  of  the  blood  irritates  and  tends 
to  the  same  result. 

All  these  influences,  where  the  vital  powers  are  at  work,  feebly 
and  under  embarrassments,  are  sufficient  to  give  chemical  laws  the 
ascendency  over  vital,  and  thus  to  produce  the  effect,  of  degener- 
ating and  destroying  the  imperfectly  organized  material  which  is 
about  to  form  a  temporary  tissue.  But,  when  once  that  tissue  is 
formed, — especially,  when  the  more  perfect  organization  of  per- 
manent tissue  is  produced,  it  is  not  to  be  expected,  that  the  kind  of 
chemical  influence  referred  to  can  be  made  to  overcome  vital  in- 
fluences. In  this  view  of  the  subject,  we  perceive,  that  to  speak 
of  pus  as  a  secretion,  is  not  philosophically  correct.  Liquor  san- 
guinis  is  secreted,  and  subsequently  undergoes  vital  changes,  upon 
the  surface.  Indeed,  if  a  surface  which  is  suppurating  be  fre- 


ULCERATION.  55 

qnently  sponged,  a  thin  fluid  only  will,  from  time  to  time,  be  dis- 
covered, and  no  pus,  as  such,  will  be  seen.  The  simple  reason  is, 
it  has  not  time  to  form. 

What  has  thus  been  said  of  the  nature  of  suppuration  throws 
important  light  on  the  question  how  the  absorption  of  pus  pro- 
duces hectic  fever.  In  the  first  place,  the  loss  of  vitality  in  what 
is  absorbed  renders  it  foreign  matter;  and  that,  when  absorbed, 
always  produces  more  or  less  constitutional  disturbance.  In  the 
next  place,  the  increased  size  of  the  pus  globules  must  render 
them  exceedingly  irritating  in  their  forced  passage  through  the 
capillaries.  And,  finally,  the  soluble  tritoxide  of  proteine,  which 
is  a  prominent  part  of  pus,  acts,  chemically,  as  an  irritant.  It  will 
even  dissolve  dead  animal  matter ;  and  it,  doubtless,  has  an  inju- 
rious effect,  wherever  it  travels  in  the  human  system. 


CHAPTER  VIII. 

ULCERATION. 

In  ulceration  there  is  a  breaking-down  and  removal  of  tissue, 
essentially  in  the  same  manner  as  in  mortification.  The  loss  of 
vitality,  in  the  part,  however,  is  gradual ;  and,  at  the  same  time, 
there  is,  in  immediate  proximity  to  the  decaying  part,  a  struggling 
and  partially  successful  effort  of  vitality.  By  this  effort,  granula- 
tions are  being  formed,  though  they  are  also  being  disintegrated, 
in  part,  and  converted  into  pus. 

In  the  case  of  an  abscess,  the  hyaline  fluid  forms  an  organized 
or  exudation  membrane,  around  a  limited  part,  and  thereby  de- 
fends the  exterior  structure  from  the  noxious  influence  of  the 
gathering  pus.  This  membrane  has  been  called  pyogenic,  on  ac- 
count of  its  supposed  office  of  secreting  pus.  We  have  seen,  how- 
ever, that  pus  is  not  a  secretion.  Still,  the  name,  for  distinction's 
sake,  may  well  enough  be  retained.  This  pyogenic  membrane 
varies  somewhat,  in  its  strength  and  influence,  according  to  cir- 
cumstances. Very  commonly,  it  affords  the  least  resistance  in  the 
direction  of  some  cutaneous  or  mucous  surface,  and  the  abscess  is 
said  to  point  in  that  direction.  The  parts  there  are  put  more  upon 


56  THORACIC    DISEASES. 

the  stretch,  the  vessels  are  more  obstructed,  the  vitality  is  dimin- 
ished, and  the  liquor  sanguinis  is  less  secreted.  Fibrous  and 
other  hard  textures  generally  resist  pretty  fully  the  progress  of  ab- 
scesses and  the  escape  of  pus.  "  Serous  membranes,  by  their 
ready  plastic  process,  first  adhere  together,  and  then  often  give 
passage  to  the  contents  cf  an  abscess  through  them,"  thereby  for- 
bidding the  escape  of  any  pus  into  the  sacs  which  they  form. 
After  an  abscess  has  opened  and  discharged  its  contents,  the  gran- 
ulation process,  to  an  extent,  gets  the  ascendancy  of  the  morbid 
chemical  influences ;  and,  though  the  superficial  layer  of  exuda- 
tion corpuscles  degenerates,  more  or  less,  into  pus,  the  healing 
process  is,  in  time,  effected,  and  the  cavity  is  obliterated. 

Sometimes  ulcers  form  superficially.  Inflammation  gives  ori- 
gin to  the  destruction  of  the  tegumentary,  and  portions  of  deeper- 
seated  tissues.  They  lose  their  vitality,  and  are  either  absorbed 
or  carried  away  with  the  pus  discharged.  The  excavation  being 
greater,  in  some  portions  than  in  others,  often  gives  a  ragged  form 
to  the  ulcer.  Sometimes,  especially  when  the  impurity  of  the 
blood  enfeebles  the  vital  power,  the  reparative  process  will  go  on 
but  imperfectly,  and  the  pus  discharged,  or  a  portion  of  it,  will 
not  be  well-formed.  It  may  be  ichorous  or  sanious,  or  may,  by 
other  characteristics,  show  the  weakness  of  the  vital  action ;  but, 
as  soon  as  the  vital  energies,  working  by  fixed  laws,  begin  to  get 
the  ascendancy,  well-formed  pus  takes  the  place  of  that  of  other 
traits,  and  granulations,  to  a  greater  or  less  extent,  restore  the  part. 

In  general,  ulceration  has  its  origin  in  a  suspension  of  the  nor- 
mal nutrition  of  the  part,  by  means  of  inflammation.  Frequently, 
however,  it  is  immediately  preceded  by  an  induration  which  is 
produced  by  some  abnormal  deposit,  either  from  the  blood  vessels, 
or  from  the  lymphatic  system,  or  from  both.  In  this  case,  "  the 
ulceration  commences  in  the  centre  of  the  induration,  because  the 
nutrient  influence  of  the  vessels  is  most  reduced,  by  the  pressure 
at  that  spot."  Sometimes,  it  would  seem,  that  the  impoverished 
and  impure  condition  of  the  blood  gives  rise  to  ulceration,  with- 
out its  being  preceded  by  induration  or  inflammation.  This  es- 
pecially happens  in  parts,  the  blood  vessels  of  which  become  con- 
gested by  posture;  and  in  the  non-vascular  textures,  which  are 
not  nourished  the  most  directly  by  .the  blood. 


MORTIFICATION  57 


CHAPTER  IX. 

MORTIFICATION. 

Mortification  consists  in  the  decay  of  animal  tissue,  in  conse- 
quence of  a  suspension  of  circulation  in  the  part,  or  of  the  blood's 
having,  in  a  great  degree,  lost  its  vital  properties.  The  part  dies; 
and,  if  the  vital  energies  in  the  parts  immediately  around  are  suf- 
ficiently energetic,  the  reparative  process  is  immediately  set  up, 
and,  by  means  of  it,  the  dead  portion  is  separated  or  sloughed  from 
the  living.  If,  however,  the  vital  power  in  the  surrounding  parts 
is  but  feeble,  and  the  separating  process  takes  place  but  slowly, 
decomposition  will,  to  an  extent,  ensue,  while  the  dead  portion 
remains  attached  to  the  living. 

For  convenience's  sake,  degrees  of  mortification  have  been  ex- 
pressed by  different  terms.  When  the  death  of  the  part  seems  en- 
tire, when  the  color  is  a  dark  bronze  or  almost  black,  and  when 
sensible  decay  is  going  forward,  the  mortification  is  called  sphace- 
lus.  On  the  other  hand,  when  vitality  seems  gradually  to  depart, 
when  the  color  is  only  livid  or  a  greenish  yellow,  and  when  decay 
is  not  yet  sensible,  the  mortification  is  called  gangrene.  These 
terms,  however,  are  not  always  used  with  precision. 

When  the  vital  energies  have  been  sufficient  to  cause  a  slough- 
ing of  the  mortified  part,  immediately  the  granulating  process  will 
appear,  attended  with  suppuration.  Sometimes,  when  a  part  is 
gangrenous,  and  even  when  its  mortification  seems  almost  entire, 
it  will  be,  in  a  measure,  supplied  with  warmth  and  moisture  from 
the  healthy  adjoining  tissue,  it  will  exhale  an  offensive  odor,  and, 
if  it  be  upon  the  surface  of  the  body,  the  cuticle  will  run  in  blis- 
ters. At  other  times,  the  mortified  portion  becomes  dark-colored, 
dry,  arid  horny,  but  does  not  rapidly  putrify.  It  is  then  called 
dry  mortification  or  dry  gangrene. 

When  the  mortification  is  internal,  as  the  matter  becomes  putrid, 
it  is  liable,  by  being  pent  up,  to  affect  the  living  body  and  produce 
constitutional  symptoms.  If,  however,  the  constitution  be  vigor- 
ous, and  the  reparative  process  be  well  established,  the  living  parts 
will  be  more  or  less  protected  from  the  infectious  influence  of  the 
8 


58  THORACIC    DISEASES. 

dead  matter;  but,  in  persons  of  feeble  constitution,  whose  blood 
is  deficient  in  plastic  power,  the  infection  will  be  felt,  and  typhoid 
or  putrid  symptoms  will  appear.  And,  in  general,  it  may  be  said, 
that  no  living  parts,  however  great  their  activity,  can  long  resist 
the  pernicious  influence  of  dead  matter  in  connexion  with  them, 
without  experiencing  a  poisoning  or  injurious  effect. 


CHAPTER  X. 

LYMPHATIC    SWELLINGS. 

Besides  the  enlargements  produced  by  inflammation  and  serous 
effusion,  there  are  forms  of  swelling  which  arise  from  an  accumu- 
lation of  lymph  in  the  part.  The  lymph  is  detained  in  the  lym- 
phatic vessels,  and  over-distends  them.  Of  course,  the  part  is 
enlarged. 

Such  an  enlargement,  when  it  exists  simply,  may  be  called 
lymphatic  congestion.  In  some  cases  of  ague,  nervous  swelling, 
&c.,  the  enlargement  is  little  more  than  congestion  of  the  lym- 
phatic vessels.  When,  for  instance,  the  face  suddenly  swells,  in 
consequence  of  diseased  teeth  and  a  disordered  condition  of  the 
nerves  connected  with  those  teeth,  the  effect  is  evidently  lym- 
phatic congestion.  So,  too,  when  the  abdomen  suddenly  puffs 
up,  by  means  of  disordered  uterine  action,  the  puffiness  is  imme- 
diately caused  by  lymph  detained  in  the  lymphatic  vessels.  The 
nerves  connected  with  this  set  of  vessels,  become  weakened  in 
their  power,  and  the  lymph  does  not  pass  with  its  normal  rapidity ; 
— it  accumulates  in  the  part  affected.  Such,  at  least,  is  my  view 
of  this  matter. 

There  are,  however,  modifications  of  this  condition.  Not  un- 
frequently,  lymph  is  detained  in  the  glands,  until  it  becomes  hard- 
ened and  assumes  a  pasty  appearance.  Inflammation  is  set  up  in 
and  around  the  glands,  and  so  the  enlargement  is  compound  in 
its  character.  It  arises  partly  from  lymphatic  congestion,  and 
partly  from  inflammation.  Scrofulous  enlargements  of  glands 
about  the  neck,  in  the  axilla,  in  the  groin,  and  in  other  localities, 
are  instances  of  this  compound  character  of  disease.  So,  also, 


TUBERCLES.  59 

are  those  scrofulous  swellings  which,  at  length,  take  on  the  char- 
acter of  abscesses.  Here,  too,  I  confidently  rank  the  case  of 
phlegmasia  dolens.  The  swelling  is  mainly  owing  to  the  lym- 
phatic congestion,  while  phlebitis  and  perhaps  inflammation  of 
different  tissues,  to  some  extent,  attend  the  lymphatic  disturbance. 


CHAPTER  XL 

TUBERCLES. 

According  to  Dr.  Wm.  B.  Carpenter,  tubercle  is  a  degenerated 
form  of  the  exudation  corpuscle.  It  is  unpossessed  of  organiza- 
tion, and  exists,  like  a  foreign  body,  in  the  tissues  in  which  it  is 
deposited.  It  consists  of  albumen,  with  a  greater  or  less  admix- 
ture of  fibrine.  It  generally  exhibits  no  other  trace  of  structure, 
than  a  congeries  of  minute  albuminous  granules,  mingled  with 
shapeless  flakes  or  filaments ;  but  cy toblasts  and  cells  may  be  oc- 
casionally detected  in  it,  especially  when  it  is  recently  formed. 

Dr.  Carpenter,  also,  supposes,  that  tuberculous  matter  is  deposi- 
ted in  persons  of  a  scrofulous  habit,  in  the  same  manner  as  what 
he  calls  organizable  lymph  is  deposited  in  persons  of  sounder  con- 
stitutions ;  or,  as  I  should  say,  in  the  same  manner  as  granula- 
tions or  exudation  membranes  are  formed.  He,  also,  further  says, 
that  "  the  difference  between  a  deposit  of  tubercle  and  the  effusion 
(I  should  say  secretion]  of  plastic  lymph  consists  in  this, — that 
the  former  is  composed  of  the  albuminous  constituent  of  the 
blood,  a  mere  chemical  compound,  which  is  riot  prepared  to  un- 
dergo organization  until  it  has  passed  through  the  condition  of 
fibrine,  whilst  the  latter  is  a  portion  of  the  vitalized  fibrine,  which 
possesses  within  itself  the  tendency  to  organization  and  only  re- 
quires the  contact  of  a  living  membrane  to  enable  it  to  pass  into 
a  regular  structure."  He,  however,  admits  "that  tubercular  mat- 
ter may  be  deposited  by  a  perversion  of  the  ordinary  process  of 
nutrition,  without  anything  like  an  inflammatory  state."  "Unor- 
ganizable  albumen  "  takes  the  place  "  of  organized  fibrine." 

That  these  views  of  Dr.  Carpenter  are  not  very  remote  from 
the  truth,  is  sufficiently  clear,  in  the  present  light  of  pathological 


60  THORACIC    DISEASES. 

science ;  and  yet,  to  my  own  mind,  it  is  equally  clear,  that  a  crude 
and  peculiar  organization  characterizes  tubercle.  It  is  something 
more  than  a  mere  chemical  compound.  It  is  a  somewhat  vital- 
ized, though  a  cacoplastic  deposit.  It  is  "  the  result,"  says  Dr.  C.  J. 
B.  WilliaTis,  "of  modified  textual  nutrition.  The  cell-germs,  by 
which  the  material  of  textures  is  renewed,  are  imperfect  at  par- 
ticular points;  a  granular  or  amorphous  matter  is  deposited  from 
the  plasma,  and  concretes  without  fibres  or  regular  cells'  being  de- 
veloped. At  this  point  a  granulation  appears,  and  gradually  hard- 
ens. When  a  granule  has  once  been  formed,  it  becomes  a  nucleus 
for  the  concretion  of  more ;  a  new  habit  or  mode  of  nourishment 
is  established  at  the  spot;  or,  to  speak  less  figuratively,  cacoplas- 
tic matter  (if  present  in  the  blood  plasma)  concretes  around  it  by 
a  process  similar  to  that  by  which  fat  attracts  fat,  or  bone  osseous 
matter.  Perhaps  the  process  is  not  wholly  unlike  that  of  crystal- 
ization.  But,  however  it  happens,  the  result  is,  that  the  granular 
tubercle  grows,  and  may  attain  the  size  of  a  millet-seed,  hemp 
seed,  or  even  a  small  cherry  stone;  or,  being  subjected  to  press- 
ure, may  slightly  spread  or  flatten  into  various  shapes. 

"The  microscopic  character  of  these  miliary  or  granular  tuber- 
cles is  the  complete  predominence  of  minute  and  often  irregular 
granules,  and  the  comparative  absence  of  fibres  and  cells,  of  which 
mere  traces  are  seen,  at  least  in  the  older  specimens.  The  gran- 
ules are  aggregated  together  by  an  amorphous  material,  the  solidi- 
ty of  which  gives  hardness  and  some  transparency  to  the  mass. 
The  chemical  nature  of  granular  tubercle  is  albuminous,  with 
some  gelatine,  and  a  little  fat,  the  latter  in  very  minute  proportion, 
and  occupying  the  centre  of  some  granules,  and  the  gelatine 
being,  probably,  the  amorphous  cement  just  noticed.  In  all  these 
characters,  we  find  a  close  analogy  to  the  granular  degeneration 
of  textures,  of  which,  doubtless,  these  deposits  are  a  kind  of 
exaggeration. 

"  Tubercles  rarely  grow  much  or  last  long,  without  exhibiting 
another  change  in  their  appearance.  They  lose  their  semi-trans- 
parency, and  become  of  an  opaque  or  dead  pale  yellow  hue,  like 
the  color  of  raw  potato  or  parsnip.  This  is  the  transformation  to 
crude  yellow  tubercle,  first  described  by  Laennec.  This  change 
is  the  result  of  a  further  degradation  or  degeneration  of  the  de- 


TUBERCLES.  61 

posit.  The  few  fibres  and  cells  which  are  to  be  detected  in  gray 
tubercle  become  indistinct,  the  interstitial  hyaline  or  amorphous 
solid  diminishes,  and  oil  globules  appear  in  its  stead,  and  the  mass 
becomes  less  coherent  and  more  granular, .  and  therefore  quite 
aplastic.  Generally,  the  change  begins  in  the  centre  of  the  mass  ; 
apparently  because,  being  devoid  of  vessels,  the  centre  is  further 
removed  from  the  vivifying  influence  of  the  blood. 

"But  tubercle  is  frequently  deposited  at  first  in  this  yellow 
opaque  state, — this  circumstance  being  a  mark  of  the  still  more 
degraded  condition  of  the  nutritive  function;  and  the  more  ex- 
tensive forms  of  tuberculous  disease  commonly  abound  in  this 
aplastic  matter.  Thus,  in  rapid  phthisis,  yellow  tubercle  com- 
monly forms  a  large  portion  of  the  deposit.  Yellow  tubercle  is 
rarely  so  hard  or  so  tough  as  the  gray  or  semi-transparent  kind  • 
and,  in  the  cases  of  rapid  deposit,  just  mentioned,  it  is  often  much 
softer  and  more  friable.  Now,  this  is  the  commencement  of  a 
change  to  which  the  lowest  forms  of  tubercle  tend, — that  of  ma- 

O  * 

turation  and  softening  into  a  cheesy  substance."  In  the  softening 
of  tubercle,  "the  deposit  becomes  less  dense,  and  loses  the  little 
trace  of  structure  which  it  possessed.  It  degenerates  into  an 
amorphous  granular  mass;  and,  being  lifeless,  it  is  no  longer  nour- 
ished. Its  granules  lose  their  cohesion  and  become  disintegrated 
by  the  chemical  action  of  the  adjoining  fluids.  Mr.  Gulliver  and 
others  have  observed  a  remarkable  increase  of  fat  globules  in  soft- 
ened tubercle.  In  fact,  from  the  time  that  tubercle  assumes  the 
opaque  form,  these  oil  globules  appear  to  increase,  until  it  either 
is  softened  and  eliminated,  or  undergoes  a  kind  of  "  petrifactive 
change," — a  chemical  and  mineral  transformation. 

But  the  microscopic  character  of  tuberculous  deposits  is  that  by 
which  they  are  specially  discriminated.  This  character  is  admira- 
bly described  by  Lebert  who,  at  present,  "is  the  highest  authority 
in  France  on  this  subject,  and  is,  perhaps  unsurpassed,  by  any 
microscopist  now  in  existence,  in  microscopic  pathology."  I  add 
a  portion  of  what  he  says  on  this  subject,  in  the  translation  of 
Dr.  John  A.  Swett  of  New  York. 

"  The  constant  elements  of  tubercle  are : 

"  1st.  A  great  number  of  molecular  granules,  perfectly  round, 
of  a  grayish-white  color,  or  with  a  slight  yellow  tint,  sometimes 


62  THORACIC    DISEASES. 

compact,  sometimes  transparent  in  their  centres,  with  a  diameter 
of  -0012  to  -0025  of  a  millimetre.  These  granules  completely  sur- 
round the  tubercle  globule,  so  that  it  is  often  difficult  to  recognize 
it  in  the  crude  yellow  tubercle.  They  are  seen  in  much  greater 
numbers,  and  quite  disaggregated,  in  the  softened  tubercle. 

"2d.  These  granules,  as  also  the  tubercle  globule,  are  united 
with  each  other  by  an  intergranular,  interglobular,  hyaline  sub- 
stance, of  considerable  consistence,  which  serves  as  a  cement  to 
the  elements  of  tubercle,  and  which  becomes  liquefied  by  soft- 
ening. 

"  3d.  If  the  two  elements  which  I  have  just  described  possess 
no  peculiarities  which  belong  to  tubercle,  and  which  do  not  dis- 
tinguish it  from  other  morbid  products,  there  is  a  third  element 
which  is  much  more  important,  which,  in  fact,  is  entirely  charac- 
teristic of,  and  peculiar  to  tubercle — the  tubercle  globule,  or  cell. 

"  The  form  of  the  tubercle  globules  is  seldom  perfectly  round, 
although  it  is  probable,  that,  at  the  time  of  their  excretion  by  the 
capillaries,  they  do  assume  a  form  more  or  less  spherical,  and  that 
they  afterwards  assume  a  less  regular  shape,  often  becoming  an- 
gular, on  account  of  their  close  juxtaposition.  Thus,  as  they 
commonly  appear  under  the  microscope,  especially  in  the  crude 
tubercle,  their  outline  is  irregular,  approaching  sometimes  to  the 
sphere,  sometimes  to  an  oval ;  but  generally  they  are  irregularly 
angular  and  many-sided,  with  the  angles  and  the  edges  rounded, 
as  is  very  evident  when  they  are  suspended  in  water  or  in  serum. 
Their  color  is  a  clear  yellow,  assuming  a  blackish  tint  when  a 
high  magnifying  power  is  employed.  Their  interior  is  irregular 
and  of  unequal  consistence,  which  gives  them  a  spotted  appear- 
ance, independently  of  the  granules  which  they  may  contain. 
But  I  have  never  been  able  to  detect  a  true  nucleus  in  these  glob- 
ules, although  they  sometimes  present  in  their  interior  the  appear- 
ance of  an  irregular  vacuum,  which  resembles  a  nucleus.  I  have 
always  examined  this  point  with  great  attention,  using  the  highest 
and  the  best  denning  magnifying  powers,  as  well  as  different  chemi- 
cal re-agents.  We  cannot  consider  the  granules,  which  are  irregu- 
larly distributed  in  the  substance  of  the  tubercle  globule,  as  nuclei. 
These  are  only  molecular  granules,  whose  diameters  seldom  reach, 
and  never  exceed,  -0025  of  a  millimetre ;  often,  indeed,  they  are 


TUBERCLES.  63 

not  more  than  -0012  to  -0015  of  a  millimetre.  These  granules, 
variable  in  number  from  3,  5,  to  10,  or  more,  are  not  regularly 
distributed,  and  are  not  all  visible  in  the  same  focus.  The  inter- 
granular  substance  of  the  globules  surrounds  them,  so  that  they 
are  not  ordinarily  encompassed  by  a  transparent  areola.  The  in- 
terior of  these  granules  appears  opaque. 

"  The  diameter  of  the  tubercle  globule  varies.  In  the  rounded 
globules,  it  ranges  between  '005  and  -0075  of  a  millimetre,  rare- 
ly extending  to  -01  of  a  millimetre.  The  oval  globules,  as  a 
mean,  are  -0075  of  a  millimetre  in  length,  and  -005  to  -006  of  a 
millimetre  in  breadth.  The  diameter  of  the  tubercle  globule  in- 
creases at  the  commencement  of  the  period  of  softening. 

"  The  diameter  of  the  tubercle  globule  varies  within  certain 
limits ;  but  this  variation  is  independent  of  age  and  of  the  tissue 
or  organ  in  which  the  deposit  has  formed.  It  is  more  easily  rec- 
ognized in  the  yellow  crude  tubercle,  than  in  the  gray  miliary 
granulation.  In  the  recent  tubercle,  the  tubercle  globule  is  de- 
tected with  difficulty,  because  it  is  concealed  by  the  interglobular 
hyaline  membrane  which  unites  the  globules,  and  by  a  large 
number  of  molecular  granules  which  surround  them. 

"It  is  important,  therefore,  in  commencing  the  study  of  the 
tubercle  globule,  to  select  for  examination  a  yellow  cheesy  tuber- 
cle, not  too  hard  nor  too  soft,  to  disaggregate  it  with  needles,  in  a 
drop  of  water,  which  can,  however,  never  be  done  completely; 
and  this  difficulty  is  one  of  the  most  striking  characteristics  of 
the  tuberculous  deposit.  It  is  well,  after  this  has  been  done,  to 
let  the  preparation  dry  a  little  between  the  plates  of  glass,  in  order 
that  as  many  globules  as  possible  may  be  seen  at  the  same  focus. 
The  distinctness  of  the  view  may  be  increased  by  a  fine  dia- 
phragm and  by  a  good  light.  A  lamp  is,  however,  not  as  favora- 
ble for  the  examination  of  tubercle  as  the  daylight ;  and,  if  the 
lamp  is  employed,  care  must  be  taken  that  the  light  is  not  too 
strong.  We  having  thus  become  familiar  with  all  the  details  of  the 
tubercle  globule,  it  will  be  easily  recognized  whenever  it  is  pres- 
ent. By  this  method,  then,  the  tuberculous  deposit  can  be  readi- 
ly distinguished  from  all  other  morbid  products,  a  result  \vhich, 
in  doubtful  cases,  no  other  mode  of  examination  is  capable  of 
producing. 


64 


THORACIC    DISEASES, 


Water  does  not  change  the  tubercle  globule.  Acetic  acid  ren- 
ders it  more  transparent  without  changing  it  much,  and  establishes 
the  absence  of  nuclei  in  its  interior.  It  is  a  very  valuable  mode 
of  distinguishing  the  tubercle  globule  from  other  globules  resem- 
bling it,  except  that  they  contain  one  or  more  nuclei.  Acetic  acid 
is  especially  useful  in  distinguishing  the  tubercle  globule  from  the 
pus  globule.  Ether  and  alcohol  react  very  slightly  upon  the  tu- 
bercle globule.  Strong  ammonia  renders  it,  at  first,  more  trans- 
parent; it  then  dissolves  the  intergranular  substance,  and  allows 
the  molecular  granules  contained  in  it  to  become  separated.  A 
concentrated  solution  of  caustic  potassa  completely  dissolves  the 
tubercle  globule.  The  concentrated  acids,  especially  the  hydro- 
chloric and  the  sulphuric  acids,  also  dissolve  it,  but  more  slowly. 

"What  is  the  position  which  the  tubercle  globule  is  entitled  to 
occupy  among  the  pathological  cells?  If  it  be  true,  that  a  perfect 
cell  is  composed  of  an  investing  membrane,  and  of  one  or  two 
nuclei,  and  of  nucleoli  in  the  interior  of  these  nuclei ;  yet  I  am 
convinced,  from  many  observations  of  pathological  cells,  as  well 
as  of  those  found  in  healthy  organs,  that  this  mode  of  cell-forma- 
tion is  by  no  means  universal,  and  only  peculiar  to  a  certain  num- 
ber of  elementary  globules.  The  tubercle  globule  appears  to  me 
to  be  one  of  the  most  simple  forms  of  pathological  cells,  being 
composed  of  an  enveloping  membrane,  containing  a  semi-liquid 
substance  and  a  certain  number  of  molecular  granules  irregularly 
scattered  through  it,  as  in  the  pyoid  globule.  This  pyoid  globule, 
however  (, which  is  a  variety  of  the  development  of  the  pus  glob- 
ule), differs  from  the  tubercle  globule  in  being  more  regularly 
spherical,  more  pale,  more  transparent,  and  by  containing  granules 
which  are  transparent  in  their  centres,  and  seated  in  the  periphery 
of  the  pyoid  globule. 

'•I  will  now  pass  to  the  study  of  the  softened  tubercle,  limiting 
myself,  for  the  present,  to  indicating  the  physical  changes  in  the 
softened  tubercle  as  revealed  by  the  microscope,  and  reserving  the 
physiological  explanation  for  another  place.  In  order  to  appreci- 
ate properly  the  changes  which  take  place  during  the  softening 
of  -the  tuberculous  matter,  the  use  of  the  microscope  is  indispen- 
sable, for  the  reason,  that  the  parts  surrounding  the  tubercles  often 
inflame  and  secrete  pus,  and  then  the  elements  of  suppuration  are 


TUBERCLES.  65 

mixed  with  those  of  tubercle.  As  the  naked  eye  cannot  discover 
all  these  details,  much  confusion  would  exist  without  the  aid  of 
the  microscope. 

"I  may  say,  in  general  terms,  that  the  principal  change  that 
occurs  in  the  tubercle,  while  softening,  consists  in  the  liquefaction 
of  the  interglobular  hyaline  substance,  which  is  sufficiently  solid 
and  consistent  in  the  crude  tubercle  to  hold  the  tubercle  globules 
in  close  union.  But,  in  the  softened  tubercle,  they  become  disag- 
gregated, separated,  although  clustered  groups  may  still  be  discov- 
ered. As  the  globules  become  free,  they  become  more  rounded, 
almost  spherical;  they  become,  at  the  same  time,  more  transpa- 
rent and  more  thin,  and  the  blastema  which  surrounds  them  be- 
comes more  granular. 

"  Both  by  the  naked  eye  and  by  the  microscope,  pus  is  fre- 
quently found  united  with  softened  tubercle.  It  would  appear 
that  the  presence  of  pus  hastens  the  decomposition  of  the  tuber- 
cle globule,  and  this  is  one  reason  why  the  matter  contained  in 
tuberculous  ulcers  is  so  often  without  tubercle  globules. 

"Finally,  it  may  be  stated,  that  the  tubercle  globule  disappears 
in  a  nearly  perfect  dissolution,  after  having  been  disaggregated 
into  granules.  These  globules,  then,  undergo  three  phases  of 
development.  They  are  at  first  closely  packed  together,  and 
compact  in  their  interior.  Then  they  separate  from  each  other 
and  increase  in  size,  which,  instead  of  being  owing  to  a  more 
perfect  development,  is,  in  fact,  the  commencement  of  decompo- 
sition, and  is  owing  to  an  endosmosis  of  the  surrounding  blastema, 
which  becomes  more  and  more  liquid.  At  last,  these  little  glob- 
ules, whose  internal  and  molecular  cohesion  has  already  been  dis- 
turbed, finally,  by  running  together,  form  a  yellow  and  a  more  or 
less  liquid  mass. 

"There  is  some  analogy  in  the  mode  in  which  the  pus  globule 
and  the  tubercle  globule  disappear.  The  former  is  disintegrated 
into  granules  before  it  can  be  absorbed. 

"  If  the  crude  tubercle  and  the  softened  tubercle  constitute  the 
first  two  stages  of  this  deposit,  and  the  diffluence  of  the  elements 
of  tubercle  the  third  stage  of  its  evolution,  there  is  still  a  fourth 
stage, — its  passage  into  a  cretaceous  state.  I  can  confirm  the 
opinion  that  this  cretaceous  transformation  of  tubercle  is  one  of 
9 


66  THORACIC    DISEASES. 

the  most  powerful  means  which  nature  employs  to  cure  the  tu- 
berculous disease.  Its  microscopic  composition  is  altogether  in 
favor  of  this  view  of  the  question.  At  the  commencement  of 
this  change,  we  can  still  recognize  a  considerable  number  of  tu- 
bercle globules,  arid  with  them  a  kind  of  mineral  dust  formed  of 
very  fine  granules,  whose  diameters  are  from  -001  to  -0015  of  a 
millimetre,  transparent  in  the  centre,  looking  black  under  a  high 
magnifying  power,  but  under  low  power,  as  well  as  by  the 
naked  eye,  having  a  yellowish-white  tint,  and  being  more  resis- 
tant to  compression  than  the  soft  elements  of  ordinary  tubercle. 
These  latter  elements  diminish  in  proportion  as  the  granular, 
amorphous,  mineral  elements  increase.  They  become  more  solid 
and  dry,  as  the  portions  capable  of  dissolution  are  absorbed.  The 
cretaceous  tubercle  often  contains  much  black  pigment,  and  many 
times  I  have  met  with  a  considerable  number  of  crystals  of  chol- 
esterine. 

"Having  described  the  elements  which  are  essential  to  tubercle, 
I  will  next  examine  other  elements  which  are  not  essential,  but 
yet  are  of  frequent  occurrence. 

"  The  pigment  infiltration,  or  melanosis,  which  is  also  met  with 
in  many  other  morbid  products,  appears  in  three  different  forms. 
1st.  As  a  granular  infiltration.  2d.  As  the  contents  of  certain 
globules,  having  a  diameter  from  -016  to  -024  of  a  millimetre,  and 
sometimes  reaching  -033  of  a  millimetre.  3d.  As  fine  granules 
contained  in  certain  normal,  or  pathological  cells.  Thus  it  is  fre- 
quently contained  in  epithelial  cells,  and  expectorated  in  abundance. 

'•  This  pigment  is  also  found  surrounding  pulmonary  tubercles, 
as  the  gray  granulation,  the  cretaceous  tubercle,  and  tuberculous 
excavations.  It  is  also  often  found  in  abundance  in  the  bronchial 
glands.  It  is  sometimes  noticed  in  the  mucous  membrane  of  the 
intestine,  and  especially  around  tubercles  of  the  peritoneum.  It 
is  a  carbonaceous  substance. 

'•  Fat,  in  the  form  of  fat  vesicles,  is  frequently  found  in  tubercles. 

11  It  is  not  uncommon  to  find  fibres  in  tubercle,  but  they  very 
rarely  belong  to  the  tuberculous  secretion.  Generally,  they  are 
fibres  of  the  tissue  of  the  organ  in  which  tubercle  is  secreted. 
Thus,  the  gray,  semi-transparent  tubercle  in  the  lungs,  often  con- 
tains the  elastic  fibres  of  the  cellular  tissue  of  the  lungs. 


TUBKRCLF.S.  6? 

'•  In  certain  rare  cases,  crystals  exist  in  tubercle.  Once  I  met 
with  three-sided  prisms  in  tuberculous  matter  from  the  lungs; 
another  time,  in  the  bronchial  glands;  and,  in  a  third  case,  rhoni- 
boidal  plates  of  cholesterine  in  softened  tubercle  in  the  neck, 
which  was  not  cretaceous. 

"  Another  element  not  unfrequently  met  with,  and  which  might 
easily  lead  to  mistakes,  are  young  epithelial  cells,  derived  from 
the  capillary  bronchi,  when  the  lung  is  cut,  having  a  diameter  of 
•0125  to  -015  of  a  millimetre.  These  are  of  an  irregularly  round- 
ed shape,  containing  a  nucleus  with  a  diameter  of  -005  of  a 
millimetre,  which  sometimes  contains  a  nucleolus,  or  a  finely 
granulated  matter.  These  cells  are  found  in  considerable  number 
around  agglomerated  masses  of  tubercle  globules,  but  never  in  the 
midst  of  them,  so  long  as  they  are  united  by  the  intercellular  hy- 
aline substance.  By  the  side  of  these  round  or  oval  young  epith- 
elial cells,  are  found  the  cylindric  epithelial  scales,  with  or  with- 
out vibratile  cilia,  which  could  not  easily  be  mistaken  for  tu- 
bercle globules. 

"  In  conclusion,  we  find,  as  the  constant  and  essential  elements 
of  tubercle,  granules,  and  an  interglobular  hyaline  substance,  and 
globules  peculiar  to  tubercle.  After  its  excretion,  the  tubercle 
first  assumes  a  compact  form,  then  it  softens,  and  at  a  still  later 
period  it  dissolves;  or  it  withers  and  becomes  cretaceous.  The 
elements  which  are  not  constant,  but  which  are  found  more  or 
less  frequently  in  tubercle,  are  melanosis  or  black  pigment,  which 
is  the  most  common,  fat,  fibres,  globules  of  a  decided  color,  and 
finally  crystals,  commonly  those  of  cholesterine. 

"As  elements  accidentally  mixed  with  tubercles,  we  often  find 
under  the  microscope  different  products  of  inflammation,  of  exu- 
dation, of  suppuration,  and  of  the  epithelial  secretion,  globules  of 
different  kinds,  which  come  from  the  tissues  surrounding  the  tu- 
bercle, but  which  are  never  met  with  in  the  midst  of  its  elements. 

<:  In  the  gray  semi-transparent  granulation  of  the  lungs,  we  al- 
ways find  a  mixture  of  areolar  fibres  with  a  grayish  hyaline  sub- 
stance and  with  tubercle  globules.  The  fibres  are  composed  of 
the  elastic  fibres  of  the  pulmonary  cellular  tissue.  The  gray  tint 
of  the  granulation  is  sometimes  heightened  by  the  admixture  of 
the  black  pigment. 


68  THORACIC    DISEASES. 

"  The  yellow  opaque  tubercle  is  identically  the  same  as  the 
gray  semi-transparent  tubercle,  only,  in  the  latter,  the  tubercle 
globules  are  smaller,  and  more  closely  packed  in  the  substance 
xvhich  surrounds  them.  The  yellowish  aspect  is  produced  by 
the  confluence  and  increased  size  and  abundance  of  the  tubercle 
globules  after  the  destruction  of  the  surrounding  fibres  which 
tended  to  separate  them,  and  at  the  same  time  the  hyaline  mem- 
brane becomes  more  opaque  and  granular. 

"  The  gray,  semi-transparent  granulation  is  not  the  constant  or 
the  necessary  commencement  of  the  tuberculous  deposit.  It  may 
occur  originally  as  the  yellow  opaque  granulation.  Very  small 
yellowish  points  make  their  appearance,  in  which  the  microscope 
discovers  a  few  fibres,  much  less  numerous  than  in  the  gray  gran- 
ulation. Their  principal  element  is  the  tubercle  globule,  and  the 
interglobular  hyaline  membrane  is  granular,  and  with  very  little 
transparency. 

"  The  liquid  which  covers  the  internal  aspect  of  tuberculous 
excavations  contains,  sometimes,  tubercle  globules  in  their  perfect 
form ;  but  generally  they  are  more  or  less  distended  by  the  soften- 
ing that  has  taken  place,  and  most  of  them  are  in  a  state  of  dif- 
fluence.  It  also  contains  pus  globules,  the  large  granular  globules 
of  inflammation,  a  viscid  mucous  fluid,  blood  globules,  pulmonary 
fibres,  black  pigment,  epithelial  scales,  three-sided  prisms,  and  fat 
vesicles. 

"  Under  this  liquid  layer,  composed  of  so  many  elements,  are 
false  membranes,  composed  of  a  fibrous  stratified  substance,  and 
containing  numerous  pus  globules. 

"  Beneath  this  layer  of  fibrine  is  the  true  lining  membrane  of 
the  excavation — it  is  organized  and  vascular.  Its  structure  is  ir- 
regularly fibrous,  and  among  the  fibres  are  numerous  small  globules. 
Sometimes  it  contains  but  very  few  blood-vessels,  and  then  the 
fibrous  tissue  is  dense,  white,  and  very  abundant,  appearing  like 
cartilage.  But  I  have  never  found  in  it  the  slightest  traces  of  the 
elements  of  cartilage. 

"  The  microscopic  examination  of  the  expectoration  in  tuber- 
culous phthisis  discloses  the  following  facts  :  The  matter  contains, 
in  the  first  place,  substances  which  are  not  at  all  specific,  as  sali- 
va mixed  with  mucus  and  epithelial  scales  from  the  mouth,  which 


CARCINOMA.  69 

latter  are  sometimes  quite  abundant;  epithelial  scales  from  the 
bronchi,  mucus,  vibriones,  blood  globules,  crystals,  black  pigment, 
globules  of  fat,  granular  globules,  and  pus  globules. 

"  Besides  these,  are  noticed  small  masses  or  little  pellicles,  which 
at  first  sight  might  be  mistaken  for  tuberculous  matter.  The  mi- 
croscope, however,  only  discloses  globules  of  pus  and  a  granular 
coagulation.  These  are  probably  false  membranes  coming  from 
tuberculous  cavities.  Again,  we  notice  masses  like  the  preceding 
in  appearance,  in  which  the  microscope  only  discloses  numerous 
molecular  granules,  which  are  probably  produced  by  diffluent  tu- 
berculous matter.  Again,  there  are  noticed  amorphous  mineral 
granules,  which,  perhaps,  come  from  cretaceous  tubercles.  And, 
finally,  we  may  meet  with  the  true  tubercle  globule.  But  this  is 
very  rare.  I  am  not  sure,  that  I  have  ever  met  with  it  so  dis- 
tinctly that  its  existence  was  not  doubtful.  Sometimes  pulmonary 
fibres  are  found  in  the  expectoration.  There  is,  then,  nothing  spe- 
cific in  the  tuberculous  expectoration." 


CHAPTER  XII. 

CARCINOMA. 

Carcinoma,  from  the  Greek  xapxivo?,  a  crab,  and  synonymous 
with  cancer,  indicates  a  disease  which  has  generally  been  consid- 
ered to  exist  in  three  distinct  forms.  These  forms  are  originally 
such,  and  not  merely  different  stages  of  the  disease;  and  they 
arise  mainly  from  the  different  proportions  and  arrangements  of  the 
elements  entering  into  the  composition  of  the  deposit.  "  These 
elements,"  Dr.  Svvett  has  well  remarked,  "area  fibrous  tissue,  and 
a  viscid  fluid,  contained  in  cells  and  called  the  cancerous  juice. 

"  If  the  fibrous  tissue  predominates,  you  will  find  the  mass 
hard  and  creaking,  when  divided  by  the  knife.  You  will  notice 
that  its  cut  surface  is  intersected  by  white  lines,  or  by  larger  mas- 
ses of  a  dense  white  structure.  In  the  midst  of  these  lines  you 
will  discover  a  finely  granulated  substance,  contained  in  cells, 
which  is  the  cancerous  juice,  and  which  may  be  pressed  out  by 
the  finger  or  scraped  off  'by  the  scalpel,  when  it  often  very  much 


THORACIC    DISEASES. 

resembles  apple-juice,  in  appearance.      This  form  of  cancer  is 
known  as  scirrhns. 

'•'  When  the  fibrous  element  is  less  distinct,  and  the  cancerous 
juice  more  abundant,  the  cancerous  mass  is  much  softer  in  texture. 
It  is  often  more  distinctly  granular;  and,  from  its  resemblance,  in 
many  cases,  to  the  substance  of  the  brain,  it  has  been  called  en- 
cep  haloid. 

"  Finally,  the  fibrous  tissue  may  be  still  more  deficient,  or  even 
entirely  absent,  and  a  jelly-like  mass,  sometimes  semi-fluid  or  even 
fluid,  and  collected  in  cells,  often  of  considerable  size  and  united 
with  cancer  cells,  may  exist,  constituting  what  has  been  called 
the  colloid  or  gelatinous  cancer." 

But,  in  addition  to  this  three-fold  division  of  cancerous  depos- 
its, there  are  minor  differences,  which  arise  from  accidental  causes. 
— One  of  these  respects  the  color.  Commonly,  the  cancerous  • 
juice  is  semi-transparent  and  of  a  yellowish- white  color.  Its  ap- 
pearance has  well  been  compared  to  that  of  apple-juice.  Some- 
times, however,  the  mixture  of  fatty  matter  gives  it  a  greater  yel- 
lowness; and  then  a  mass,  of  the  proper  consistence,  bears  the  re- 
semblance of  a  tuberculous  deposit ;  or,  if  it  be  more  fluid  in  form, 
it  very  much  resembles  pus.  Sometimes,  too,  the  juice  is  of  a 
milky-white  color,  and  gives  to  the  fibrous  deposit  an  aspect  al- 
most white.  Often  the  fibrous  deposit  is  of  a  rosy-red  appearance  ; 
or  portions  of  it  may  take  on  a  dark,  and  almost  black  or  melan- 
otic  appearance. 

The  cancerous  mass,  also,  varies  much  in  form  and  general 
character.  Sometimes,  it  is  exceedingly  vascular,  and  the  vessels 
are  easily  ruptured.  Often,  it  is  loose  and  spongy  in  texture  like 
the  lungs.  Again,  its  fibrous  structure  is  close  and  unyielding. 
Sometimes,  there  is  a  large  undivided  mass;  sometimes,  minute 
particles  are  deposited  in  clusters;  and,  sometimes,  there  is  an  un- 
defined infiltration  into  the  tissues  involved. 

Generally,  the  deposit  is  at  first  of  pretty  firm  consistence.  In 
process  of  time,  it  softens  and  discharges  a  fluid.  It  is  then  called 
a  cancerous  ulcer.  The  terms  fungus  hasmatodes,  rose  cancer, 
&c.,  are  very  commonly  employed  to  designate  some  of  the  ap- 
pearances now  described. 

Chemically  considered,  the  most  abundant  element  in  the  com- 


CARCINOMA.  71 

position  of  cancer  is  albumen.  "It,  also,  contains,"  says  Dr. 
Svvett,  "some  fatty  matter,  and  some  fibrine,  with  inorganic  salts, 
— as  the  sub-phosphate  of  lime,  the  carbonates  of  lime,  soda,  and 
magnesia,  the  hydrochlorates  of  soda  and  of  potassa,  the  tartrate 
of  soda,  and  the  oxide  of  iron."' 

It  is  only  microscopically,  however,  that  cancer,  as  such,  can  be 
recognized  with  certainty.  The  elementary  cancer  cells  or  glob- 
ules differ  from  all  other  cells,  whether  concerned  with  healthy 
or  with  diseased  structures.  The  cancer  cells  are  not,  indeed, 
found  alone,  but  they  are  mixed  with  other  forms  of  matter;  and 
these  accidental  ingredients  assist  in  varying  the  visual  appearance 
of  the  mass,  as  a  whole.  It  is  now  admitted,  that  inflammatory 
indurations,  non-malignant  fibrous  tumors,  &c.,  when  the  eye  is 
the  only  test  employed,  are  liable  to  be  mistaken  for  true  carcino- 
ma. Hence  the  importance  of  a  means  of  diagnosis  on  which  re- 
liance may  be  unerringly  placed.  This  means  is  found  in  micro- 
scopy. 

In  illustration  of  the  microscopical  character  of  cancer,  I  quote 
from  Lebert's  work  on  Pathological  Anatomy,  as  translated  by 
Dr.  S  \vett. 

"Authors  of  much  merit  have  denied  that  the  microscopic  ele- 
ments of  cancer  were  characteristic.  I  have  arrived  at  an  oppo- 
site conclusion,  and  I  maintain  that  the  cancer  globule  has  strik- 
ing characteristics  which  distinguish  it  from  every  other  form  of 
morbid  product.  It  must  not  be  forgotten,  that  there  are  certain 
general  forms  of  cells  and  of  nuclei,  the  types  of  which  are  met 
with  in  very  different  products.  Cut  this  I  maintain,  that  the 
different  pathological  products  which  are  composed  of  elementary 
globules,  individually  present  certain  characteristics  by  which  they 
can  be  distinguished  by  those  somewhat  accustomed  to  the  use  of 
the  microscope.  I  will  go  even  further,  and  state  that  the  cancer 
globule  is  one  of  the  cells  which  possess  the  most  striking  char- 
acteristic features  to  distinguish  it  from  every  other  kind  of  cell. 
It  is  important,  however,  to  add,  that  the  cancer  globule  is  sub- 
ject to  very  many  variations;  but  I  hope,  by  pointing  out  these 
varieties  carefully,  and  at  the  same  time  by  explaining  the  sources 
of  mistake,  and  the  difficulties  in  the  diagnosis,  to  place  before 
the  reader  their  peculiar  characteristics. 


72  THORACIC    DISEASES. 

"Not  only  the  globules  of  cancer,  but  even  their  nuclei,  are 
larger  than  the  entire  tubercle  globule.  The  globules  of  scirrhus 
have  a  diameter  of  -0175  to  -02  of  a  millimetre,  and  sometimes 
of  '025  of  a  millimetre.  Their  outline  is  regular,  their  appear- 
ance pale,  and  their  surface  is  finely  dotted  with  minute  granules, 
which  are  situated  between  the  investing  membrane  and  the  nu- 
cleus. This  nucleus  is  commonly  single,  but  sometimes  double, 
and  with  a  strongly  marked  outline,  round  or  oval,  and  with  a 
diameter  of  from  -0125  to  -015  of  a  millimetre.  These  nuclei 
are  often  found  freed  from  their  investing  membrane.  When  this 
is  the  case,  and  a  large  number  of  these  free  nuclei  are  clustered 
together,  they  resemble  somewhat  tubercle  globules ;  but  the  dif- 
ferences in  the  diameters,  in  the  outline,  in  the  central  substance, 
and  in  the  existence  of  a  certain  number  of  perfect  cancerous 
globules,  will  remove  any  doubt  that  may  exist. 

"  The  globules  of  encephaloid,  which  are  very  much  like  those 
of  scirrhus ;  or  rather  the  nucleus  of  the  true  encephaloid  glob- 
ule— for  authors  have  generally  mistaken  the  nucleus  for  the  per- 
fect globule — has  a  diameter  from  -01  to  -015  of  a  millimetre. 
Its  shape  is  a  very  regular  sphere,  or  oval,  with  a  marked  outline 
finely  shaded  all  around  its  internal  circumference,  containing,  be- 
sides a  fine  granular  matter,  one,  two,  rarely  three  round  nucleoli, 
with  diameters  of  from  -0025  to  -0033  of  a  millimetre,  and  trans- 
parent at  the  centre.  A  fact  which  establishes  the  diagnosis  still 
more  clearly  is.  that,  when  the  globules  are  perfectly  formed,  they 
are  surrounded  by  an  investing  membrane,  which  is  often  irregu- 
lar in  shape.  The  whole  globule  thus  represented  has  a  diameter 
of  -015  to  -02  of  a  millimetre,  and  sometimes  even  of  -035  of  a 
millimetre,  and  possesses  characteristics  peculiar  to  itself. 

"The  cancer  globule  is  composed  of  an  enveloping  membrane, 
and  a  nucleus  which  contains  nucleoli.  The  diameter  of  the 
external  cell  varies  in  different  cases.  Its  mean  diameter  is  -02 
of  a  millimetre.  Sometimes  it  is  only  -015  of  a  millimetre. 
Yery  often  it  is  much  greater,  extending  to  -03  of  a  millimetre, 
or  even  beyond  that  point.  Its  shape  is  round  or  ovoid — round 
more  frequently  in  the  globule  of  encephaloid,  a  little  elongat- 
ed in  the  globule  of  scirrhus.  In  many  cases  it  is  easy  to  trace 
the  progress  of  one  of  these  forms,  as  it  passes  into  the  other 


CARCINOMA. 


73 


form.  Very  frequently  this  external  enveloping  membrane  as- 
sumes many  different  forms.  It  is  generally  more  flattened  than 
the  nucleus.  Sometimes  it  is  pale,  and  perfectly  transparent.  At 
other  times  it  is  covered  by  fine  dots;  and  quite  frequently  it  is  so 
filled  with  granules  that  it  exactly  resembles  the  large  granular 
globules  of  inflammation.  It  is  also  not  uncommon  to  meet 
with  both  regular  arid  irregular  globules,  which  contain  a  certain 
number  of  nuclei ;  and  we  may  discover  large  parent  cells,  with  a 
diameter  reaching  even  to  -05  of  a  millimetre,  of  a  rounded  or 
oval  shape,  which  contain  four,  five,  six,  or  even  a  greater  num- 
ber of  nuclei.  At  other  times  we  meet  with  large  membranous 
expansions,  in  which  we  can  distinguish  a  considerable  number 
of  nuclei,  surrounded  by  a  granular  and  dotted  mass. 

"  The  nuclei  vary  in  their  diameters  from  -0075  to  -02  of  a  mil- 
limetre. The  smaller  are  found  chiefly  in  the  perfect  globules  of 
scirrhus.  The  large  round  or  elliptical  nuclei,  with  diameters  ex- 
tending from  -015  to  -02  of  a  millimetre,  are  principally  found  in 
the  encephaloid  cancer.  In  some  forms  of  cancer  these  nuclei 
constitute  so  decidedly  the  predominating  element  under  the  mi- 
croscope, that  we  might  be  tempted  to  assume  that  they  were  the 
type  of  the  cancer  globule,  did  we  not  observe  these  same  glob- 
ules in  their  more  perfect  form,  that  is,  with  their  enveloping  mem- 
brane, in  other  cases  of  cancer.  These  nuclei  are  sometimes 
very  pale.  At  other  times,  and  this  is  especially  the  case  in  scirrhus, 
their  outline  is  very  distinct.  In  many  cases  of  encephaloid  they 
present  a  characteristic  shading  at  their  whole  circumference.  In 
a  certain  number  of  cases  the  enveloping  membrane  of  the  cancer 
globule  is  elongated,  pointed  at  each  end,  and  even  at  several 
points  of  its  circumference.  It  then  bears  some  resemblance  to 
the  fusiform  fibro-plastic  bodies.  It  can  always,  however,  be 
readily  distinguished  from  these  bodies  by  its  much  greater  size, 
by  being  much  less  elongated,  and  by  its  characteristic  nuclei  and 
rmcleoli. 

"If  the  nuclei  and  nucleoli  of  the  cancer  globule  always  pos- 
sessed the  distinct  form  which  I  have  just  described,  nothing  could 
be  more  easy  than  to  detect  them  by  a  microscopic  examination. 
Bat,  as  it  generally  happens  that  cancer  is  mixed  with  much  fatty 
matter,  the  nuclei  are  found  to  undergo  different  changes  on  this 
10 


74  THOHACIC    DISEASES. 

account.  Thus  we  often  find  them  filled  with  granules  and  small 
grumous  masses.  Sometimes,  indeed,  they  are  infiltrated  with  a 
homogeneous  and  confluent  fatty  matter. 

"  The  nucleoli  have  a  diameter  which  varies  from  -0025  to 
'0033  of  a  millimetre,  and  even  to  -01  of  a  millimetre.  Their 
number  is  from  one  to  five.  But,  as  the  nuclei  which  contain 
them  are  somewhat  thick  and  spherical,  we  cannot  recognize  them 
all  under  the  microscope  at  the  same  focal  distance.  These  nu- 
cleoli have  a  peculiar  character.  Their  outline  is  distinct,  but 
their  interior  is  seldom  transparent — ordinarily  it  is  dull  and  hom- 
ogeneous. I  was  for  a  long  time  in  doubt  what  these  nucleoli 
were;  but  I  have  recently  discovered  that  they  are  imperfectly 
developed  nuclei.  In  examining  some  large  nucleoli  under  a  mag- 
nifying power  of  1000  diameters,  I  saw  that  they  contained  two 
or  three  secondary  nucleoli. 

"It  is  not  uncommon  to  meet,  in  cancer,  with  large  concentric 
cells  with  a  diameter  from  -04  to  -05  of  a  millimetre,  and  with 
thick  walls  inclosing  many  concentric  globules. 

"  The  cancer  globule  appears  to  me  to  be  formed  in  this  way  : 
The  capillaries  excrete  the  cancerous  matter  in  a  liquid  state.  In 
this  liquid,  nuclei  form,  and  soon  after  nucleoli.  Possibly  the  nu- 
cleoli may  form  first.  Around  the  nucleus,  molecules  of  the  liquid 
blastema  first  excreted  arrange  themselves,  so  as  to  form  irregular 
enveloping  shreds,  or  regular  rounded  or  oval  globules.  It  may 
possibly  be  the  case  that  these  concentric  globules  are  only  ordina- 
ry cancer  globules,  all  the  portions  of  which  are  remarkably  devel- 
oped. I  have  also  seen  the  cancer  globules  assume  the  appearance 
of  clustering  when  they  were  filled  with  granules  of  fat,  and  when 
the  nuclei  also  were  deformed  by  the  infiltration  of  fatty  matter. 

'•'It  is  not  reasonable  to  suppose  that  the  cancer  globules,  which 
are  first  secreted,  continue  to  exist  for  a  long  time.  After  a  time 
they  become  deformed,  they  lose  their  distinct  outline,  and  are  fi- 
nally dissolved  into  granules.  At  the  same  time,  the  excreted 
blastema  which  is  constantly  being  poured  out  by  the  vessels, 
forms  new  cells.  Thus,  a  certain  number  of  the  cancer  globules 
appear  incompletely  developed,  others  are  well  developed,  and  a 
certain  number  are  undergoing  decomposition. 

"  The  cancer  globule  of  scirrhus  is  ordinarily  furnished  with  an 


CARCINOMA.  75 

enveloping  membrane,  which  is  round,  ovoid,  or  irregular  in  shape. 
Its  mean  diameter  varies  from  -015  to  -02  of  a  millimetre.  It  is 
finely  dotted  all  around  the  nucleus.  This  nucleus  is  small,  its 
diameter  varying  from  -0075  to  -01  of  a  millimetre.  Its  outline 
is  very  sharp,  and  it  exhibits,  in  its  interior,  granules  and  little 
masses  (grumeaux),  and  sometimes  nucleoli. 

"  The  cancer  globule  of  encephaloid  is  surrounded  by  an  en- 
velope, regular  or  irregular  in  shape,  having  a  diameter  between 
•02  and  -03  of  a  millimetre.  The  nucleus  is  spherical,  or  very 
often  elliptical,  pale,  shaded  at  its  circumference,  and  containing 
from  one  to  three  very  distinct  nucleoli.  Generally,  as  already 
stated,  the  nuclei  are  seen  under  the  microscope  in  greater  num- 
ber than  the  perfect  cells.  Frequently  every  form  intermediate 
to  these  two  types  of  the  cancer  globule  will  be  noticed. 

"Next  to  the  cancer  globule,  which  is  the  characteristic  element, 
is  the  fibrous  element,  which  is  sometimes  the  predominating  ele- 
ment. It  presents  very  different  appearances  in  different  cases. 
In  scirrhus,  it  is  formed  by  a  network  of  fibres  arranged  in  bun- 
dles, which  cross  each  other  in  every  direction,  and  communicate 
with  each  other  by  fibres,  which  pass  from  one  bundle  to  another. 
The  primitive  fibres,  in  this  case,  are  well  defined.  They  are  del- 
icate, and  do  not  exceed  in  breadth  the  -0025  of  a  millimetre. 
They  are  generally  less  tortuous  than  the  fibres  of  ordinary  cellu- 
lar tissue.  In  some  cases  these  fibres  interlace  with  each  other 
without  being  arranged  in  bundles.  In  certain  organs,  especially 
in  cancer  of  the  mamma,  there  are  numerous  elastic  fibres.  In 
some  exceptional  cases,  I  have  met  with  a  fibroid  network,  in- 
closing in  its  meshes  cancer  globules  and  resembling  exactly  co- 
agulated fibrine.  In  the  soft  encephaloid  cancer,  the  fibres  are 
pale  and  delicate,  and  much  less  numerous  than  in  scirrhus.  Nev- 
ertheless, I  have  met  with  cases  of  medullary  cancer,  in  which  the 
encephaloid  matter  was  inclosed  in  a  dense  and  fasciculated  fibrous 
stroma. 

"  Fusiform  bodies,  such  as  are  met  with  in  other  morbid  prod- 
ucts, are  very  frequently  seen  in  cancer.  They  are  distinguished 
from  the  fusiform  cancer  globule  by  the  difference  in  their  nuclei, 
that  of  the  cancer  globules  being  much  larger. 

"  These  fibres,  these  fusiform  fibre-plastic  globules  are  formed 


76  THORACIC    DISEASES. 

from  the  exuded  blastema,  as  is  also  fat,  pigment,  and  other  sub- 
stances. 

"  After  the  cancer  globules,  the  fibres,  and  the  fusiform  bodies, 
the  substance  which  is  met  with  most  frequently  and  abundantly 
in  cancer,  is  fat.  It  is  seldom  absent,  and  it  is  sometimes  so  abun- 
dant and  so  mixed  with  the  cancer  globules,  that  they  can  hardly 
be  distinguished.  The  fatty  element  occurs  under  the  forms  of 
granules,  of  free  fat  vesicles,  fatty  spots,  and  cholesterine.  The 
granules  are  commonly  found  in  abundance  outside  the  cancer 
globules  ;  but  very  often,  also,  they  exist  in  their  interior,  and  then 
we  can  distinctly  trace  the  change  from  a  simple  cancer  globule  to 
that  which  resembles  exactly  the  large  granular  globules  of  inflam- 
mation. Frequently,  these  granules  are  deposited  in  the  nuclei 
of  encephaloid  globules.  But  that  which  renders  these  globules 
not  easily  recognizable,  is  the  fact  that  fat  is  frequently  depos- 
ited in  them  which  is  confluent  and  homogeneous  in  its  character. 
Their  outline  is  thus  altered,  and  it  requires  great  attention  to 
distinguish  them.  It  is  these  globules  which  constitute  the  fatty 
matter  which  looks  like  tubercle,  an  appearance  noticed  especially 
in  sarcocele. 

"  Large  granular  globules  analogous  to  those  noticed  as  the  prod- 
uct of  inflammation,  with  a  diameter  of  from  -02  to  -03  of  a  mil- 
limetre, are  commonly  noticed  in  cancer.  I  have  already  stated 
that  the  cancer  globule  when  infiltrated  with  fat,  may  assume  the 
appearance  of  these  inflammatory  globules.  But  I  think  that  the 
true  inflammatory  globule  is  also  often  found  in  cancer.  When  it 
is  examined  by  a  low  power  and  by  direct  light,  it  appears  in 
groups  of  a  dull  white  or  yellowish  aspect.  With  a  high  power, 
and  by  reflected  light,  it  appears  of  a  blackish-brown  color.  It  is 
usually  so  spherical,  that  it  can  be  burst  by  compression,  and 
made  to  discharge  numerous  granules.  These  globules  are  found 
in  all  kinds  of  cancer.  I  have  sometimes  seen  them  existing  as  a 
general  infiltration  into  the  cancerous  mass,  and  sometimes  form- 
ing a  network  of  a  dull-white  color,  constituting  the  reticulated 
figures  so  well  described  by  Muller.  They  can  sometimes  be 
enucleated  and  studied  separately. 

"  The  black  pigment  or  melanosis,  both  in  the  form  of  granules 
and  of  globules,  is  found  in  both  scirrhus  and  encephaloid  cancers. 


MELANOSIS.  77 

"  I  have  also  noticed  a  peculiar  coloring  matter,  of  a  yellowish 
tint,  which  I  have  named  Xantliosis.  It  varies  from  a  saffron  to 
an  orange  tint.  It  appears  to  be  a  kind  of  fatty  matter. 

"  Crystals  of  cholesterine  are  one  of  the  most  common  elements 
of  cancer.  I  have  also  seen  prismatic  needles  in  cancerous  depos- 
its; also,  mineral  concretions,  amorphous  or  bone-like,  yet  with- 
out the  structure  of  bone. 

"All  the  forms  of  cancer  present  the  evidences  of  vascularity. 

"The  colloid  or  jelly-like  cancer  is  as  well  recognized  a  form 
of  the  disease  as  scirrhus  or  encephaloid.  The  cancerous  tissue, 
especially  the  encephaloid,  sometimes  constitutes  the  base  of  the 
tumor,  and  then  the  cancer  globules  are  only  found  in  the  deeper 
portions.  In  this  case  the  gelatinous  matter  does  not  contain  the 
true  elements  of  cancer.  We  find  a  network  of  fibres  forming 
large  areolae,  and  filled  by  a  transparent  matter,  containing  pale 
granular  globules.  This  colloid  matter  does  not  appear  to  be  dif- 
ferent from  that  noticed  as  the  product  of  inflammation,  or  as  the 
contents  of  various  kinds  of  benignant  tumors.  It  only  differs 
from  it  by  being  combined  with  encephaloid.  But,  in  other  cases, 
these  areolse  are  filled  by  large  cells  or  semi-transparent  lobules, 
which  contain  numerous  cancer  globules  and  nuclei. 


CHAPTER  XIII. 

MELANOSIS. 

The  term  melanosis,  is  derived  from  the  Greek  word  fxsXa?,  sig- 
nifying black.  It  is  a  disease  in  which  there  is  the  deposit  of  a 
dark  unorganized  substance  in  some  portion  or  portions  of  the  sys- 
tem. As  exhibited  in  the  solid  tissues,  the  deposit  commonly  has 
a  viscous  appearance,  strikingly  resembling  the  vitreous  humor  of 
the  eye,  and  is,  in  color,  very  much  like  the  pigmentum  nigrum. 
It  has  no  smell  nor  taste.  It  is  soluble  in  water;  and,  when  dis- 
solved, will  stain  like  Indian  ink.  There  are,  however,  different 
shades  of  color, — it  sometimes  exhibiting  a  brown  and  sometimes 
even  a  yellowish  hue. 

Hard  melanotic  deposits,  unlike  tubercle  and  scirrhus,  do  not 


78  THORACIC    DISEASES. 

soften  down  at  any  stage  of  their  existence.  Sometimes,  from 
the  part  where  the  deposit  exists,  a  dark-colored  fungus  will  arise, 
resembling  fungus  haematodes,  and  probably  being  of  essentially 
the  same  nature.  On  the  other  hand,  where  carcinoma  previously 
exists, — especially  the  encephaloid  variety, — a  melanotic  deposit 
not  unfrequently  takes  place.  Sometimes  absorbent  glands, — en- 
larged as  in  scrofulous  disease, — become  blackened  by  a  deposition 
of  melanotic  matter.  In  such  cases,  of  course,  the  substance  of 
the  tumor  is  mainly  organized  structure, — the  melanosis  doing  lit- 
tle more  than  give  the  coloring. 

Sometimes,  as  is  the  case  with  scirrhus,  we  have  melanotic  tu- 
bera.  occurring  as  a  secondary  form  of  the  disease,  and  appearing 
simultaneously  in  various  parts  of  the  system.  Indeed,  scarcely 
any  organ  or  tissue  is  exempt  from  liability  to  be  affected  by  it. 
The  lungs,  the  pleura,  the  heart,  the  pericardium,  the  liver,  the 
spleen,  the  uterus,  the  ovaria,  the  bladder,  the  peritoneum,  the  ali- 
mentary canal,  the  areolar  and  mucous  tissues  generally,  the 
muscles,  the  skin,  and  even  the  bones  are  subject  to  the  affection. 
So,  also,  are  false  membranes,  or  the  depositions  of  organized  lymph, 
which  take  place  upon  previously  inflamed  serous  membranes. 

Occasionally,  melanotic  matter  appears  in  a  fluid  form.  In  this 
case,  a  cyst  is  filled  with  a  dark  liquid,  which,  in  its  general  fea- 
tures, precisely  resembles  the  solid  deposits.  It  seems,  however, 
to  be  originally  fluid,  and  not  the  result  of  a  converted  solid. 

That,  in  this  disease,  the  blood  itself  is  impregnated  with  par- 
ticles of  melanotic  matter,  which  really  give  rise  to  the  formations 
in  the  solid  tissues,  is  evident ;  and,  not  unfrequently,  it  is  easy 
to  detect  these  particles,  by  a  chemical  analysis. 

The  discovery  of  melanosis,  as  a  disease,  is  claimed  by  Dupuy- 
tren.     It  was,  however,  first  described  by  Laennec.     He  repre- 
sented it  as  existing  under  the  following  four  forms. 
1st,  Masses  enclosed  in  cysts. 
2d,  Masses  without  cysts. 
3d,  Infiltration  of  the  tissue  of  organs. 
4th,  Deposition  on  the  surface  of  organs. 

This  division,  it  is  clear,  presents  the  leading  distinctive  features 
of  the  disease.  Dr.  Carswell,  however,  has  suggested  another  ar- 
rangement more  comprehensive  and  various,  as  follows. 


MELANOSIS.  79 

Origin, — A  modification  of  secretion. 
Locality. — 1st,  Tissues,  systems,  arid  organs ; 

a,  In  the  substance  and  on  the  surface  of  organs, 

b,  In  the  cavities  of  hollow  organs.. 
2d,  New  formations. 

Form, — 1st,  Punctiform, 
2d,  Tuberiform, 
3d,  Stratiform, 
4th,  Liquiform. 
Seat, — 1st,  Molecular  structure  of  organs, 

2d,  The  blood. 

As  there  are  other  morbid  states  of  the  system  and  products 
presenting  distinctive  characters,  similar  to  those  of  melanosis,  Dr. 
Carswell  has  also  given  us  a  tabular  view  of  what  he  calls  spuri- 
ous melanosis,  in  distinction  from  the  true.  The  following  is  his 
arrangement. 

Origin, — A,  Introduction  of  carbonaceous  matter, 

B,  Action  of  chemical  agents, 

C,  Stagnation  of  the  blood. 
Locality, — Of  the  first  kind,  the  lungs. 

Of  the  second  kind,  the  digestive  organs,  the  surface 
of  serous  and  mucous  membranes,  the  cavities  of 
hollow  organs,  new  formations. 
Form, — Of  the  first  kind,  uniform. 

Of  the  second  kind,  1st,  punctiform,  2d,  ramiform,  3d, 

stratiform,  4th,  liquiform. 

Of  the  third  kind,  1st,  punctiform,  2d,  ramiform. 
Seat, — 1st,  The  blood,  contained  in  its  proper  vessels,  or  effused, 

2d,  Pulmonary  tissue,  cellular,  and  membranous.* 
Persons,  suffering  this  affection,  sometimes  discharge  a  dark  and 
almost  black  secretion  from  the  intestines,- the  stomach,  and  even 
the  cystis.  Under  these  circumstances,  the  old  authors  termed 
the  disease  melocna — the  black  disease.  The  morbid  secretions, 
in  all  these  cases,  are  evidently  melanotic;  and,  aside  from  the 
natural  secretions  with  which  they  are  mixed,  are  scentless  and 
tasteless. 

°See  Cyclopedia  of  Practical  Medicine,  Volume  2d,  Page  86th. 


80  THORACIC    DISEASES. 

The  pathology  of  this  disease  is  not  yet,  it  is  true,  fully  under- 
stood. The  melanotic  discharge,  however,  so  far  as  it  has  been 
analyzed,  is  found  to  contain  the  important  elements  of  the  blood, 
— fibrine,  albumen,  &c.;  but,  in  addition,  nearly  one  third  of  the 
quantity  is  a  highly  carbonized  and  abnormal  substance. 

That  the  disease  is  one  producing  general  and  decided  debility 
will  readily  be  inferred  from  the  few  hints  given  above,  respect- 
ing its  pathology.  The  depraved  condition  of  the  blood,  of 
course,  renders  it,  at  best,  an  inadequate  stimulant  to  the  nervous 
system;  but,  especially,  when  the  alvine  and  other  discharges  are 
melanotic,  the  nutrient  and  stimulating  portions  of  the  blood  are 
abnormally  removed,  in  such  quantities,  as  greatly  to  exhaust  the 
vital  powers. 

In  conclusion,  I  will  only  add,  that  various  new  formations, 
such  as  tubercle,  carcinoma,  and  melanosis,  may  exist  simultane- 
ously in  the  body  and  in  the  same  organ ;  yet  each  is  as  distinct 
in  its  nature,  as  are  the  influences  by  which  one  organ  is  atrophied 
another  hypertrophied,  one  indurated  another  softened,  at  the 
same  time. 


CHAPTER  XIV. 

NON-MALIGNANT    TUMORS. 

Tumors  in  general  differ  from  hypertrophy  and  euplastic  de- 
posits in  the  peculiarity  of  their  structure,  or  their  kind  of  vitali- 
ty. They  differ  from  cacoplastic  and  aplastic  deposits  in  their 
possessing  a  higher  degree  of  organization,  that  is,  their  degree  of 
vitality.  They  are  new  structures;  though  some  of  them,  in 
general  characters,  and  most  of  them,  in  elementary  composition, 
have  a  resemblance  to  healthy  textures. 

Tumors  may  be  divided  into  malignant  and  non-malignant. 
The  various  forms  of  carcinoma,  already  generally  considered, 
constitute  essentially  the  class  of  malignant  tumors.  The  non- 
malignant  may  be  sub-divided  into  different  classes,  though  it  is 
difficult  or  impossible  to  draw  a  clear  line  of  demarcation  between 
some  of  these  classes. 


NON-MALIGNANT    TUMORS.  8i 

NON-MALIGNANT  TUMORS  are,  in  general,  those  growths  which 
occur  in  any  part  of  the  body  without  tending  to  infect  other 
parts, — which,  though  arising  among,  yet  do  not  invade  the 
healthy  structures,  and  which  prove  injurious  only  by  their  bulk, 
their  position,  or  their  obstruction  of  the  nourishment  of  the 
body.  The  principal  portion  of  them  may  be  included  in  one  or 
the  other  of  two  classes. 

The  first  of  these  classes  is  that  of  common  encysted  tumors. 
These  tumors  consist  of  a  shut  sac,  containing  either  a  liquid  or 
a  solid  substance.  The  sac  is  formed  so  as  to  appear  like  areolar 
tissue  condensed,  or  like  serous  or  fibrous  tissue.  The  liquid 
contents  may  be  serum,  blood,  or  pus,  or  a  mixture  of  different 
ingredients.  The  solid  contents  may  be  either  adipose,  or  fibrous, 
or  sarcomatous,  or  cartilaginous  matter;  or  they,  too,  may  be  o.f 
a  mixed  character,  and  may  possess  various  kinds  of  structure. 
The  solid  contents,  and  the  sacs  of  the  tumors  in  the  cases  of 
both  the  solid  and  the  liquid  contents,  are  formed  by  altered  vital 
properties  in  the  cells,  or  primary  granules,  or  some  of  the  mole- 
cules of  the  textures,  in  some  state  of  their  progression.  These 
molecules  grow  in  modes  more  or  less  peculiar,  and  under  influ- 
ences more  or  less  independent  of  the  adjoining  healthy  parts. 

The  second  of  the  two  classes  of  non-malignant  tumors  referred 
to  is  that  of  hydatids.  These,  in  character,  approximate  malig- 
nant tumors,  in  some  respects.  They  are  quite  detached  from 
healthy  tissues,  and  are,  perhaps,  more  peculiar,  in  structure  and 
contents,  than  any  other  morbid  growths.  They  seem  to  possess 
a  vitality,  in  themselves  and  independent  of  the  parts  with  which 
they  are  physically  connected.  That  vitality,  it  is  true,  is  of  a 
low  grade,  but  is  real.  They  have  a  power  of  self-nutrition, 
manifest  in  the  growth  and  structure  of  their  walls ; — a  power  of 
secretion,  shown  by  the  j^eculiarity  of  their  limpid  and  colorless 
contents ;  and  a  power  of  reproduction  by  gemmation,  the  young 
being  developed  between  the  layers  of  the  parent  cyst,  and  thrown 
off,  either  internally  or  externally,  according  to  the  species.  Ac- 
cording to  Professor  Owen,  the  hydatid  is  "an  organized  being, 
consisting  of  a  globular  bag,  which  is  composed  of  condensed 
albuminous  matter,  of  a  laminated  texture,  and  containing  a  lim- 
pid colorless  fluid,  with  a  little  albuminous,  and  a  greater  propor- 
11 


82  THORACIC    DISEASES. 

tion  of  gelatinous  substance."  Whether,  however,  it  is  an  ani- 
mal or  a  vegetable,  the  Professor  is  slow  to  decide.  But,  surely, 
it  can  scarcely  be  considered  an  animal,  as  it  neither  feels  nor 
moves.  It  has  no  contractile  power,  arid  is  impassive  under  the 
application  of  stimuli.  It  evidently  has  nothing  but  organic  or 
vegetable  life ;  and  it  grows  in  the  system,  as  the  plant  grows  in 
the  earth.  It  is,  however,  a  nucleated  cell,  from  the  interior  of 
which  are  developed  nuclei  and  nucleoli,  the  germs  of  young 
cells ;  and.  whether  animal  or  vegetable,  it  would  seem,  that  it 
must  be,  in  its  origin,  an  offset  from  healthy  structure.  Certain 
molecules,  in  a  way  not  understood,  must,  at  first,  assume  this 
abnormal  form  and  detached  life. 

Hydatids  are  found  in  the  lungs,  liver,  spleen,  kidneys,  uterus, 
and  even  in  the  mammse.  Their  serous  or  protective  cysts  are 
formed  much  like  those  of  common  encysted  tumors.  Their 
existence  supposes  a  state  of  cachexia  or  mal-nutrition  in  the  sys- 
tem. They  injure  the  system  and  destroy  the  health,  by  their 
bulk  and  position,  by  their  compressing,  displacing,  and  irritating 
some  of  the  organs,  and  by  the  atrophy  and  inflammation  of  tex- 
tures which  they  cause.  Their  cysts  contain  laminated  matter 
more  or  less  opaque,  which  is  evidently  the  debris  of  collapsed 
hydatids;  and,  with  this,  sometimes  a  quantity  of  yellowish, 
opaque,  pultaceous  matter,  consisting  of  granules,  imperfect  cells, 
fat,  and  other  substances,  deposited  from  the  surface  of  the  sac 
and  degenerated  so  as  to  be  aplastic. 

Among  non-malignant  tumors  have,  also,  been  reckoned  those 
which  are  vascular  or  erectile.  These  consist  of  a  congeries  of 
blood-vessels  of  considerable  size,  apparently  enlarged  capillaries, 
with  more  or  less  connecting  filamentous  tissue.  Their  structure, 
however,  or  their  kind  of  vitality  does  not  seem  to  be  materially 
different  from  that  of  euplastic  deposits.  When  they  are  supplied 
by  large  arteries,  they  are  florid  in  color  and  pulsate,  and,  if  them- 
selves large,  give  a  bellows  or  rasping  sound  with  the  pulsation, 
like  what  is  heard  in  bronchocele  or  goitre.  When  the  arterial 
communication  is  not  free,  they  exhibit  the  darker  hue  of  venous 
blood. 

There  are  various  other  modifications  of  non-malignant  tumors, 
the  consideration  of  which  is  not  necessary  to  my  present  purpose, 


DIAGNOSIS. SYMPTOMS.  83 


DIVISION  II. 

DIAGNOSIS. 


Diagnosis  is  originally  a  Greek  term,  Siayvugis,  signifying  the 
art  of  distinguishing  or  discerning.  Medically  applied,  however, 
it  imports  either  a  discriminating  acquaintance  with  disease,  or  the 
science  which  gives  that  acquaintance. 

As  a  science,  diagnosis  teaches  the  various  methods  of  detect- 
ing existing  pathological  conditions.  In  other  words,  it  illustrates 
the  phenomena  attendant  on  the  different  forms  of  disease. 
These  phenomena  may  be  general  in  their  character,  or  special; 
they  may  be  constitutional  or  local  ;  they  may  disclose  themselves 
only  to  the  patient,  or  they  may  be  manifest  to  the  senses  of 
another. 

In  what  follows,  I  shall  attempt  an  explanation  of  such  topics 
as  are  important  in  understanding  the  nature  of  diseases,  and  yet 
are  liable  to  fail  of  being  accurately  comprehended.  My  remarks 
will  apply  mainly  to  diseases  of  the  thorax,  though  I  shall  devel- 
op the  principles  of  physical  diagnosis,  in  their  application  gener- 
ally. 


CHAPTER  I. 

SYMPTOMS. 

The  symptoms  by  which  the  knowledge  of  disease  is  gained, 
may  be  divided  into  rational  and  physical  symptoms. 

According  to  this  division,  the  rational  symptoms  embrace 
those  which  we  learn  through  the  medium  of  the  patient's  mind. 
Thus,  pain  or  any  peculiar  sensation,  and  its  locality,  are  made 
known  to  us  by  the  intellectual  and  communicating  faculties  of 
the  patient.  The  physical  symptoms,  on  the  contrary,  reveal 
themselves  to  us,  through  our  own  physical  senses.  By  the  eye, 
for  instance,  we  perceive  the  form  and  the  countenance  of  dis- 


84  THORACIC    DISEASES. 

ease.  By  the  ear,  we  take  cognizance  of  a  diseased  action  of 
the  heart  and  lungs,  as,  also,  of  many  changed  conditions  of  the 
structure  of  those  organs.  By  the  touch,  we  learn  the  character 
of  the  pulse,  the  consistency  of  the  tissues,  and  the  position  and 
relation  of  various  organs.  The  sense  of  smell  alone  will  often 
decide  the  character  of  a  disease,  as  in  the  case  of  cancerous  and 
febrile  affections.  Even  the  taste  has  sometimes  been  employed 
upon  the  excretions,  to  detect  the  existing  malady. 

This  division,  though  simple,  is  of  but  little  practical  utility ; 
and,  hence,  different  classifications  have  been  suggested. 

In  reference  to  pulmonary  diseases,  Dr.  John  A.  Swett  of  New 
York,  adopts  the  following  division  of  symptoms. 

"The  constitutional  symptoms, — which  are  the  changes  pro- 
duced by  these  diseases,  in  the  general  system  and  in  remote 
organs : 

"  The  rational  symptoms., — which  are  the  changes  produced,  by 
a  perversion  of  the  healthy  functions,  or  of  the  physiological  ac- 
tion of  the  lungs : 

;t  And,  finally,  the  physical  signs, — which  are  produced  by  phy- 
sical changes  in  the  structure  and  condition  of  these  organs." 

According  to  this  division,  the  furred  tongue,  the  excited  pulse, 
and  the  hot  skin  produced  by  pneumonitis,  for  instance,  are  consti- 
tutional symptoms.  The  cough,  the  expectoration,  and  the  dys- 
pnoea are  rational  symptoms ;  while  the  dulness  on  percussion, 
the  shrill  bronchial  sound  in  respiration,  and  the  like  evidences  of 
the  disease  are  physical  signs.  This  distinction,  we  may,  if  we 
choose,  apply  to  the  indications  of  other  diseases,  as  well  as  those 
of  the  lungs. 

Sometimes,  symptoms  have  been  divided  into  general  and 
physical.  When  this  division  is  employed,  the  phrase  general 
symptoms  is  intended  to  embrace  what  Dr.  Swett  would  include 
under  the  two  heads  of  constitutional  and  rational. 

A  better  division  is  into  general  symptoms  and  special.  The 
former  class  embraces  phenomena  which  respect  the  constitution 
generally,  or  parts  remote  from  the  immediate  seat  of  the  disease. 
The  latter  includes  the  indications  which  arise  more  directly  from 
the  part  affected,  or  what  Dr.  Swett  would  place  in  the  two  class- 
es of  rational  symptoms  and  physical. 


TOPOGRAPHICAL    TERMS.  85 

Sometimes,  and  with  much  propriety,  a  technical  distinction  is 
made  between  symptoms  and  signs.  According  to  this  distinc- 
tion, symptoms  are  the  existing  phenomena,  as  they  appear  to  all, 
without  revealing  any  condition  of  things  as  their  cause.  These 
same  phenomena  become  signs,  when  they  are  understood  to  in- 
dicate some  particular  state  of  the  system.  Thus  a  certain  crack- 
ling sound,  proceeding  from  the  thorax,  gives,  to  the  uninstructed 
man,  no  important  information  whatever.  He  knows  not  of 
what  disease  it  is  indicative,  or  whether,  even,  it  may  not  accom- 
pany a  state  of  health.  It  is,  to  him,  a  mere  symptom.  To  the 
intelligent  physician,  however,  it  is  something  more.  It  speaks 
the  existence  of  incipient  pneumonitis,  and  is,  therefore,  called  a 
sign  of  that  disease. 

Several  symptoms,  existing  together,  may  render  certain  the 
existence  of  a  particular  disease,  though  any  one  of  them,  by 
itself  considered,  gives  but  a  doubtful  indication.  Such  a  collec- 
tion of  symptoms  is  called  a  diagnostic  sign.  By  comparing 
present  symptoms  with  those  which  have  preceded,  at  different 
times,  we  judge  of  the  prospect  for  the  future,  and,  thereby, 
make  the  succession  a  prognostic  sign.  A  pathognomonic  sign 
is  one  which  attends  but  a  single  condition  of  things,  and,  there- 
fore, makes  that  condition  absolutely  certain. 

In  general,  however,  without  an  accurate  regard  to  such  dis- 
tinctions as  the  above,  we  apply  the  terms,  physical  symptoms  and 
physical  signs,  rather  indiscriminately,  to  those  indications  of 
disease  which  are  embraced  in  auscultation,  percussion,  and  their 
kindred  means  of  diagnosis. 


CHAPTER  II. 

TOPOGRAPHICAL    TERMS. 

To  assist  in  describing  the  physical  examination  of  a  patient, 
it  is  convenient  to  have  certain  topographical  terms,  marking  dif- 
ferent superficial  portions  of  the  thorax. 

For  this  purpose,  we  may  divide  the  anterior  portion  into  three 
parts,  on  each  side  of  the  sternum.  The  superior,  extending 


86  THORACIC    DISEASES. 

from  the  summit  of  the  lungs  to  the  top  of  the  third  rib,  is  the 
right  and  the  left  superior  third.  This  region,  on  each  side, 
which  may  be  called  the  supra-mammary,  is  important;  and.  for 
further  convenience,  may  be  sub-divided  into  the  post-clavicular 
space,  or  that  partially  behind  and  partially  above  the  clavicle  ; — 
the  clavicular,  corresponding  to  the  clavicle : — and  the  sub-clavi- 
cular, beneath  the  clavicle.  The  middle  third,  on  each  side, 
which  may  be  called  the  mammary  region,  may  be  made  to 
extend  from  the  top  of  the  third  rib  to  the  top  of  the  sixth.  The 
inferior  third,  on  each  side,  will,  of  course,  extend  from  the  top 
of  the  sixth  rib  to  the  inferior  margin  of  the  thorax.  This  may 
be  called  the  infra-mammary  region.  Sometimes,  too,  we  give, 
to  certain  localities  of  the  anterior  portion  of  the  thorax,  other 
names  according  to  anatomical  relations,  as  the  prcecordial  region, 
the  sternal  region,  &c. 

The  posterior  portion  of  the  thorax  may  be  divided  into  thirds, 
the  superior  extending  from  the  top  of  the  shoulders  to  a  line 
drawn  horizontally  over  the  spine  of  the  scapulas.  This  may  be 
called  the  superior  dorsal  region.  The  second  third  may  be 
called  the  middle  dorsal  region.  It  extends,  from  the  lower  mar- 
gin of  the  superior  third,  to  another  horizontal  line  drawn  so  as 
to  touch  the  inferior  angles  of  the  scapulas.  This  may  be  called 
the  inferior  dorsal  region.  Each  of  these  three  regions  may  be 
sub-divided,  by  the  spine  of  the  back,  into  the  right  and  the  left 
parts  of  the  regions  severally.  Here,  likewise,  we  sometimes 
derive,  from  anatomical  parts,  other  terms  to  designate  particular 
localities ;  and  we  speak  of  the  scapular  regions,  the  intra-scapu- 
lar,  the  dorsal,  &c. 

The  spaces  in  the  axillae  and  above  the  fourth  rib  on  each  side 
may  be  called  the  axillary  regions.  The  lateral  spaces  beneath 
these,  extending  downward  to  the  seventh  ribs,  may  be  called  the 
lateral  regions.  And,  sometimes,  the  narrow  spaces  at  the  very 
tops  of  the  shoulders,  extending  from  the  acromion  processes  to 
the  neck  are  called  the  humeral  regions. 

In  like  manner,  for  examining  the  abdomen  (including  the 
pelvis),  we  have  a  topography  sufficiently  accurate,  in  the  follow- 
ing delineation.  Suppose  a  line,  drawn  horizontally  around  the 
body,  so  as  to  touch  the  extremity  of  the  ensiform  cartilage.  This 


THE    POSITION    OF    THE    PATIENT.  87 

will  define,  near  enough  for  practical  purposes,  the  superior  boun- 
dary of  the  abdomen.  Suppose  a  second  line,  drawn  parallel  to 
the  first  and  touching  the  lowest  portion  of  the  last  false  ribs. 
Between  these  two  lines,  we  have  a  zone  or  belt  across  the  abdo- 
men. Suppose,  now,  a  third  line,  drawn  parallel  to  the  former 
two  and  touching  the  crest  of  each  ilium.  Between  this  and  the 
second,  we  have  a  second  zone ;  and,  below  this,  we  have  a  third 
zone.  Suppose,  now,  we  raise  a  line,  vertically,  on  each  side  of 
the  abdomen,  from  the  anterior  spinous  process  of  the  ilium,  so 
as  to  cut  the  horizontal  lines  at  right  angles.  This  will  divide 
each  zone  into  three  regions.  The  middle  region  of  the  superior 
zone  may  be  called  the  epigastric ;  and  those  on  each  side  the 
right  and  the  left  hypochondriac.  The  middle  region  of  the 
middle  zone  may  be  called  the  umbilical;  and  those  on  each  side 
the  right  and  the  left  iliac.  The  middle  region  of  the  lowest 
zone  may  be  called  the  hypogastric ;  and  those  on  each  side  the 
inguinal.  Sometimes,  terms  designating  particular  parts  of  the 
superficies  of  this  cavity  are  suggested  by  other  anatomical  con- 
siderations, or  by  the  position  of  certain  viscera  within.  Hence, 
we  speak  of  the  pubic  region,  the  hepatic,  the  gastric,  &c. 


CHAPTER  III. 

THE   POSITION    OF    THE    PATIENT. 

For  interpreting  the  constitutional  and  rational  symptoms  gen- 
erally no  specific  rules  need  be  given ;  but,  to  be  taught  correctly 
by  physical  signs,  various  directions  must  be  carefully  observed. 
Such  of  these  as  relate  to  the  position  of  the  patient  I  will  now 
briefly  point  out. 

For  succussion,  the  upright  posture  is  mostly,  though  not  al- 
ways, required.  For  palpation,  both  the  upright  and  the  recum- 
bent posture  are  necessary  in  different  cases,  and,  sometimes,  in 
the  same  case.  Abdominal  and  pelvic  examinations  mainly  de- 
mand the  recumbent  posture,  and  generally  a  dorsal  decubitus, — 
sometimes,  however,  one  partly  lateral.  Inspection  and  mensura- 
tion usually  require,  each,  the  upright  posture ;  though,  from  the  re- 


88  THORACIC    DISEASES. 

cumbent,  with  dorsal  decubitus,  some  information  may  be  gained. 

For  percussion,  the  proper  position  of  the  patient  varies  accord- 
ing to  the  relation  and  circumstances  of  the  part  to  be  examined. 
In  abdominal  examinations,  the  recumbent  posture  is  generally 
needed,  and  almost  always  dorsal  decubitus.  In  thoracic  exami- 
nations, however,  the  case  is  different.  Ordinarily,  the  upright 
posture,  but  sometimes  the  recumbent,  and  sometimes  both  in 
connexion  are  required.  When  the  upright  posture  is  to  be  as- 
sumed, if  the  patient  is  well  able  to  leave  his  bed,  I  choose  to 
have  him  seated  in  a  convenient  chair.  Let  the  muscles  of  his 
chest  be  put  somewhat  upon  the  stretch,  and  the  skin  be  rather 
closely  drawn,  so  as  to  render  the  parietes  as  tense  and  elastic  as 
convenient. 

When  the  percussion  is  anterior,  the  shoulders  should  be  thrown 
slightly  backwards,  so  as  to  give  a  little  tension  to  the  pectoral 
muscles ;  and  the  arms  should  hang  easily  by  the  sides,  or  the 
hands  be  laid  forward  upon  the  thighs.  In  posterior  percussion, 
on  the  contrary,  the  patient  should  lean  forward,  and  firmly  clasp 
his  arms  in  front.  The  dorsal  and  cervical  vertebras  thus  forming 
a  curve,  the  scapulas  will  be  drawn  away  from  the  spine?  and  the 
muscles  of  the  back  will  be  rendered  suitably  tense.  To  percuss 
either  axilla,  let  the  arms  be  raised,  and  the  palms  of  the  hands 
rest  lightly  on  the  top  of  the  head. 

If,  however,  the  feebleness  of  the  patient  forbids  his  being 
seated  in  a  chair,  he  may  sit  upright  in  his  bed ;  or,  if  too  feeble 
for  that,  he  may  be  percussed  with  accuracy,  while  recumbent. 
For  anterior  percussion,  let  him  lie  evenly  upon  his  back,  with  his 
head  and  shoulders  but  slightly  raised,  and  with  no  such  eleva- 
tion or  depression  of  any  portion  of  the  body  as  shall  vary  the 
symmetry  of  his  form.  For  posterior  percussion,  he  may  be 
turned  upon  his  face  and  abdomen.  For  axillary  percussion,  he 
may  lie  partially  on  the  opposite  side. 

For  auscultation,  essentially  the  same  rules  are  to  be  observed, 
in  regard  to  the  position  of  the  patient,  as  have  been  given  for 
observance  in  percussion.  Less  attention,  however,  needs  be 
paid  to  the  tension  of  the  muscles  and  the  skin ;  as,  in  the  suita- 
ble application  of  the  ear  to  hear,  this  object  will  be  sufficiently 
accomplished.  When  the  strength  of  the  patient  does  not  allow 


SUCCUSSION. PALPATION.  89 

of  his  assuming  the  erect  posture,  he  may  be  ausculted,  with 
sufficient  accuracy,  in  bed.  Let  his  position,  when  necessary,  be 
varied  from  dorsal  decubitus  to  lateral,  and  even  abdominal  and 
facial.  When  his  prostration  by  disease  is  considerable,  the 
symptoms  recognized  from  the  anterior  part  of  the  thorax  will 
usually  be  found  decisive;  and,  consequently,  the  dorsal  decubi- 
tus only  will  be  necessary. 


CHAPTER    IV. 

SUCCUSSION. 

Of  all  the  means  of  physical  diagnosis,  this  is  of  the  least  im- 
portance. The  term  signifies  a  shaking;  and  the  act  consists  in 
suddenly  agitating  a  patient  with  the  view  of  detecting  the  exis- 
tence of  a  fluid  in  some  one  of  the  cavities  of  the  body, — partic- 
ularly, one  of  the  pleural  sacs.  Seizing,  by  the  shoulders,  an 
individual,  as  he  is  ordinarily  seated,  strongly  jolt  or  shock 
his  whole  frame.  In  this  way,  the  sound  of  a  contained  fluid 
may  sometimes  be  heard,  like  that  of  a  liquid  in  a  cask  or  bottle 
that  is  forcibly  agitated.  This  has  been  called  the  metalic  splash. 
Sometimes,  the  patient  m  bed  is  able  so  to  shake  himself  as  to 
give  the  splashing  sound  of  the  water,  in  the  thorax.  Even 
water  in  the  pericardium  has  occasionally  been,  by  succussion, 
detected.  The  art  was  known  to  Hippocrates,  and  has,  hence, 
sometimes  been  termed  Hippocratic  succussion. 

There  is,  however,  but  little  occasion  to  employ  this  method 
of  detecting  the  existence  of  water  in  a  cavity,  as  ordinarily  it  is 
made  perfectly  evident  by  other  means  of  diagnosis. 


CHAPTER    V. 

PALPATION. 

The  matter  of  palpation  is  of  a  little  more  practical  utility  than 

succussion.     The   term  signifies  feeling  or  handling ;  and  the  act 

consists  in  the  application  of  the  hand  or  fingers  to  the  part  to  be 

examined.     Thus,  if,  while  a  person  is  speaking,  the  hand  be  ap- 

12 


90  THORACIC    DISEASES. 

plied  to  the  parieties  of  the  thorax,  a  tremor  will  ordinarily  be 
felt;  and  the  character  of  this  will  vary  according  to  the  condi- 
tion of  the  viscera  immediately  within.  If  no  tremor  appears, 
that  negative  circumstance  has  a  language  of  its  own.  The  en- 
largement of  an  internal  organ,  as  the  liver,  the  existence  of  a 
tumor  or  of  an  aneurism,  an  abnormal  action  of  the  heart,  and  the 
fluctuation  of  the  liquid  in  some  forms  of  dropsy  may  sometimes 
be  detected  by  the  hand. 

Palpation,  however,  like  succussion,  is,  at  present,  but  little  used  ; 
as,  in  most  cases,  we  have  surer  and  better  means  of  diagnosis. 


CHAPTER   VI. 

INSPECTION. 

Rising  a  little  higher  in  the  scale  of  importance,  we  come  to 
the  subject  of  inspection.  This  consists  in  an  ocular  survey  of 
the  patient,  for  the  purpose  of  judging,  by  some  recognized  want 
of  symmetry,  or  other  abnormal  condition  if  it  exists,  in  what 
manner  and  to  what  extent,  there  is  a  departure  from  health. 

To  apply,  with  effect,  to  the  chest,  this  means  of  diagnosis, 
the  clothing  of  that  portion  of  the  body,  must  be  entirely  remov- 
ed, and  the  attitude  of  the  patient  must  be  such  as  not  unnatural- 
ly to  vary  the  relation  of  those  parts  which,  in  health,  should  be 
found  symmetrical.  In  this  condition,  any  considerable  lack  of 
symmetry  is  easily  detected  by  the  eye.  So,  also,  are  many  such 
prominences  and  depressions  as  are  created  by  disease,  whether 
they  destroy  the  relation  which  one  part  of  the  body  bears  to  the 
other,  or  not.  Of  this  nature,  are  the  fulness  of  the  precordial 
region,  the  enlargement  or  contraction  of  one  of  the  sides,  the 
elevation  or  depression  of  one  of  the  shoulders,  the  contraction 
about  the  clavicles  increasing  their  apparent  prominence,  and  like 
variations  from  the  standard  of  health.  The  phenomena,  thus  in- 
spected, become  signs  of  the  disease  existing  within.  So,  al- 
so, do  certain  abnormal  motions  of  the  chest,  neck,  or  abdomen, 
occurring  in  respiration  or  with  the  impulses  of  the  heart.  Even 
the  absence  of  the  proper  movement  may  indicate  disease;  and 
this  absence  may  be  made  known  by  inspection. 


MENSURATION. PERCUSSION.  91 


CHAPTER  VII. 

MENSURATION. 

As  an  aid  to  inspection,  and  as  a  matter  not  far  from  tantamount 
in  importance,  is  mensuration.  This  consists  in  the  admeasure- 
ment of  certain  parts  whose  form  is  altered  by  disease,  and  in  the 
comparison  of  that  admeasurement  with  the  standard  of  health. 
Passing  a  tape  or  measuring  line  around  the  thorax,  we  may,  by 
means  of  it,  learn  very  accurately  the  comparative  fulness  of  the 
two  sides.  We  'may,  also,  by  comparing  the  circumference  at  the 
superior  with  that  at  the  inferior  portion  of  the  thorax,  decide 
whether  the  relation  of  those  portions  is  consistent  with  the  con- 
dition of  health.  By  mensuration,  too,  we  may  determine  the  po- 
sition of  the  nipples  with  reference  to  the  sternum,  to  the  clavicles, 
and  to  the  spinous  processes  of  the  ilia;  and,  by  so  doing,  may 
gain  diagnostic  signs  of  certain  diseases. 


CHAPTER  VIII. 

PERCUSSION. 

None  of  the  previously  considered  means  of  diagnosis  compare, 
at  all  favorably  in  importance,  with  percussion.  By  this  is  meant 
the  method  of  detecting  the  condition  of  internal  organs,  from 
the  character  of  the  sound  produced,  when  the  surface  of  the 
body  directly  over  those  organs  receives  the  force  of  a  light  blow. 
It  was  invented  by  Avenbrugger. 

The  sounds  produced  by  percussion  are  divided,  generally,  into 
two, — the  resonant  and  the  dull. 

The  resonant  sound  is  heard  on  percussion  over  a  space  filled 
with  air  or  gas,  usually  termed  an  empty  space. 

The  dull  sound  is  heard  on  percussion  over  a  solid  or  a  liquid 
substance. 

The  former  of  these  sounds  is  illustrated  in  the  case  of  striking 
upon  an  empty  barrel  or  cask; — the  latter,  by  the  same  act,  when 
the  barrel  or  cask  is  filled  with  liquid.  Or  we  have  a  modified  il- 


THORACIC    DISEASES. 

lustration  in  the  case  of  a  barrel  partially  filled  with  liquid.  Strike 
upon  that  barrel  above  the  surface  of  the  liquid,  and  you  hear  a 
hollow  or  resonant  sound.  Strike  below  the  surface,  and  you 
hear  a  dull  or  a  flat  sound. 

In  percussing  over  any  of  the  cavities  of  the  human  body,  if 
no  internal  viscus  lies  near  the  paries  or  wall,  we  have  a  very  res- 
onant sound.  If  the  cavity  is  filled  partly  with  air  or  gas,  and 
partly  with  solid  viscera  intermixed,  or  if  there  be  within  a  viscus 
of  a  spongy  character,  we  have  a  less  resonant  sound.  If  a  solid 
of  medium  density  lies  within,  we  have  a  slightly  dull  sound.  If 
a  very  dense  solid  or  a  liquid  within  receives  the  force  of  the 
percussion,  we  have  a  very  dull,  often  called  a  flat  sound.  Hence 
we  speak  of  very  resonant,  resonant,  dull,  and  very  dull  or  flat 
sounds.  We  even  use  other  qualifying  terms  to  mark  nicer  differ- 
ences, according  to  circumstances,  as  the  ear  is  able  to  distin- 
guish those  differences. 

There  is,  however,  one  peculiarity  of  sound,  or  one  adventitious 
sound  of  percussion,  which  deserves  a  moment's  special  consider- 
ation. It  is  usually  called  the  cracked-pot  sound, — in  French, 
bruit  de  pot  fele.  The  name  sufficiently  explains  itself.  It  is  a 
kind  of  cracking  or  chinking  sound.  It  may  be  imperfectly  imi- 
tated, by  clasping  the  hands  together,  in  such  a  manner,  that  the 
palmar  surfaces  shall  constitute  the  walls  of  a  small  cavity,  and 
then  striking  the  dorsal  portion  of  one  of  the  hands  on  the  knee 
or  some  solid  substance. 

The  sound  is  heard  when  percussing  over  a  cavity,  with  thin 
walls;  as,  for  example,  over  a  tuberculous  cavity  near  the  surface 
of  the  lung,  when  the  pulmonary  and  costal  portions  of  the  pleu- 
ra are  united  at  the  part  concerned.  It  may  be  heard,  when  a 
disease  of  the  lung  draws  a  portion  of  it  away  from  the  thoracic 
wall,  so  as  to  leave  a  hollow  space. 

Percussion  is  either  immediate  or  mediate.  Immediate  percus- 
sion supposes  the  blow  to  be  made  immediately  upon-the  body  of 
the  patient, — no  substance  intervening.  Mediate  percussion,  on 
the  contrary,  supposes  some  substance  interposed  or  placed  on  the 
part  to  be  percussed,  primarily  to  receive  the  impulse  and  to  com- 
municate it  to  the  body  beneath. 

Immediate  percussion  was  the  form  in  which  the  art  was  first 


PERCUSSION.  93 

practiced.  By  it,  Averibrugger  threw  much  new  light  on  the  na- 
ture of  many  diseases;  and,  shortly  after,  Corvisart,  adopting  and 
advocating  it,  contributed  much  to  establish  its  reputation.  As 
thus  practiced,  however,  the  art  was  imperfect. 

At  length,  M.  Piorry,  physician  to  the  Hotel  Dieu  of  Paris,  in- 
vented mediate  percussion,  and  applied  it,  with  greater  success,  to 
the  investigation  of  the  nature  of  diseases;  and  now  the  increased 
advantages  and  accuracy  of  the  latter  mode  have  caused  it  entire- 
ly to  supercede  the  former.  In  mediate  percussion,  as  at  first  em- 
ployed, a  dense  body,  of  a  small  superficial  extent,  was  placed  in 
contact  with  that  portion  of  the  patient  to  be  percussed ;  and  was 
made  to  receive  an  impulse  from  the  fingers  or  some  artificial  per- 
cussor,  used  after  the  manner  of  a  small  mallet.  This  body  took 
the  name  pleximeter,  or,  as  it  has  been  sometimes  written,  ples- 
simeter,  signifying  a  measure  or  measurer  of  percussion. 

The  object  of  the  pleximeter  is  to  gather  the  sound  from  some 
little  extent  of  surface,  and  thereby  produce  a  stronger  impression 
upon  the  ear.  Besides,  if  the  patient  be  thin  in  flesh  and  very 
sensitive,  immediate  percussion  will  give  him  uneasiness,  and  will 
be  too  impatiently  borne  for  its  practical  advantages ;  or,  on  the 
other  hand,  if  there  be  a  rather  abundant  amount  of  adipose  tis- 
sue, or  if  the  areolar  tissue  be  somewhat  infiltrated  with  serum, 
the  condition  of  the  internal  organs  will  not  be  truly  represented. 

The  pleximeters  in  earliest  use  were  made  of  metal  and  ivory. 
Afterwards,  leather  and  other  substances  were  tried ;  and,  of  late 
years,  a  square  piece  of  caoutchouc,  about  one  fourth  or  one  third 
of  an  inch  in  thickness,  and  about  two  inches  in  diameter,  has 
been  recommended.  This,  which  was  first  proposed  by  Dr.  J. 
B.  S.  Jackson  of  Boston,  Mass.,  has  an  advantage  over  the  mate- 
rials which  are  more  solid  and  scarcely  elastic,  in  its  power  of  ac- 
commodation to  any  unevenness  of  surface,  and  the  transmission 
thereby  of  a  greater  volume  of  sound.  By  being,  too,  of  a  den- 
sity nearly  similar  to  that  of  the  tissues  over  which  it  is  placed, 
it  represents  more  truly  the  quality  of  sound  created  by  the  con- 
dition of  the  organs  and  space  within.  A  hard  unyielding  sub- 
stance necessarily  gives  some  degree  of  sharpness  even  to  sounds 
which  would  otherwise  be  measurably  resonant ;  and,  besides,  if  the 
instrument  shall  happen  not  to  be  applied  with  sufficient  firmness 


94  THORACIC    DISEASE&. 

and  care,  the  true  sound  is  liable  to  be  masked  by  a  clack  of  the 
air  beneath.  To  do  justice  to  the  quality  of  sound,  the  plexime- 
ter  should  gently  compress  and  measurably  displace  any  tissues 
adapted  to  prevent  the  natural  vibrations  of  the  part  percussed. 

In  accomplishing  this  end,  nothing  is  found  to  answer  so  well 
as  one  of  the  fingers.  For  convenience,  we  take  either  the  index 
or  the  middle  finger  of  the  left  hand.  This  is  easily  adapted  to 
any  irregularities  of  the  surface  to  which  it  is  applied,  and  is,  in 
every  respect,  decidedly  superior  to  any  artificial  instrument  that 
human  ingenuity  can  invent. 

Ordinarily,  the  palmar  surface  of  the  finger  should  be  presented 
to  the  body  of  the  patient,  and  the  percussion  should  be  made  on 
the  dorsal  surface.  The  reason  of  this  direction  is,  the  softer  por- 
tion of  the  finger  best  adapts  itself  and  covers  the  part  from  which 
we  wish  to  gather  the  sound;  while  the  harder  portion,  by  means 
of  its  density,  best  conveys  and  represents  the  sound  to  the  ear. 
In  some  conditions,  however,  it  is  convenient  and  desirable  to  re- 
verse the  finger.  By  its  natural  curve,  for  instance,  it  better  fits 
certain  depressions,  as  those  above  or  behind  the  clavicle,  some 
places  between  the  ribs,  and  other  parts;  and  the  advantage  gained 
in  the  matter  of  adaptation  may  more  than  counterbalance  any 
consequent  defect  in  the  communication  of  the  sound. 

In  percussing  certain  symmetrical  portions  of  the  body — of  the 
chest  particularly — ,when  we  wish  to  compare  one  sound  with  the 
other,  a  caution  or  two  must  be  observed ; — Do  not  make  one  of 
the  above-named  applications  of  the  finger  to  one  part,  and  the 
other  to  the  other  part.  It  may  prevent  a  discriminating  compari- 
son of  the  sounds.  Be  careful,  also,  to  press  the  finger  equally 
firm,  and  to  apply  it  in  analogous  directions,  in  both  instances, 
as  well  as  on  analogous  portions.  In  comparing  the  two  sides  of 
the  chest,  for  instance,  we  must  percuss  at  equal  distances  from  the 
sternum,  and  in  corresponding  intercostal  spaces  or  over  corres- 
ponding ribs. 

For  the  purpose  of  giving  the  blow  in  percussion,  an  instrument 
has  been  contrived  by  Dr.  Jacob  Bigelow  of  Boston,  Mass.  It 
consists  of  a  handle,  about  six  inches  in  length,  made  of  whale- 
bone or  tough  but  slightly  elastic  wood,  to  one  extremity  of  which 
is  attached  a  ball,  about  an  inch  in  diameter.  This  ball  is  made  in- 


PERCUSSION.  95 

ternally  of  some  solid  substance,  and  covered  pretty  thickly  with 
velvet  or  buckskin,  so  as  to  be  externally  quite  elastic.  Besides, 
however,  the  trouble  of  preparing  it  and  keeping  it  by  one  for  use, 
it  muffles  the  sound,  and  forbids  an  accurate  discrimination. 

Incomparably  the  best  percussor  every  one  has  received  as  the 
boon  of  nature.  It  is  found  in  the  right  hand  simply.  Of  this, 
we  may  use  directly  one  or  both  of  the  index  and  middle  fingers  ; 
or  with  these  two  we  may  unite,  also,  the  ring  finger,  taking  care 
to  place  them  so  that  their  extremities  shall  form  a  line,  and  all 
be  equally  impressed  on  the  finger  of  the  left  hand  used  as  a  plex- 
imeter.  The  phalanges  should  be  so  arranged  that  the  third  set 
shall  form  nearly  a  right  angle  with  the  first,  and  constitute  the 
head,  so  to  say,  of  a  light  mallet  or  hammer.  In  that  position 
they  must  be  firmly  retained.  Of  course,  the  blow  brings  only 
the  extremities  of  the  fingers  in  contact  with  the  pleximeter. 

The  act  of  percussion  should  be  performed,  as  far  as  possible, 
without  any  motion  of  the  arm,  or  even  of  the  forearm.  The 
wrist  becomes  the  moveable  point  or  hinge,  and  the  metacarpus 
the  handle  of  the  percussor.  By  using  any  portion  of  the  arm, 
we  almost  necessarily  strike  a  blow  too  firm  for  the  convenience 
of  the  patient  or  for  delicacy  of  sound.  We  almost  necessarily, 
too,  allow  the  contact  to  exist  for  a  moment  instead  of  instantly 
withdrawing  the  fingers.  The  consequence  is,  we  prevent  the 
proper  vibration  of  the  parts  concerned,  and  thereby  obscure  the 
sound.  When  motion  is  made  from  the  wrist  only,  it  is  much 
more  easy  to  give  suddenness  to  the  impulsion,  and  thus  to  favor 
the  reaction  of  elasticity. 

When  percussing  over  thick  adipose  tissue  or  tissue  infiltrated 
with  serum,  we  must  necessarily  use  more  force  than  is  desirable 
where  the  parietes  are  thin  and  the  internal  organs  delicately  sen- 
sitive. In  such  a  case,  we  should  not  fail  to  employ  together,  the 
three  fingers  before  named  ;  but  we  must  be  particularly  careful 
to  have  them  suddenly  rebound  after  the  blow.  It  is  the  quick- 
ness, rather  than  the  force  of  the  impulsion,  which  gives  the  prop- 
er clearness  and  sharpness  to  the  sound.  On  the  contrary,  when 
we  are  concerned  with  tissues  unusually  thin, — when,  for  instance, 
we  are  percussing  the  chests  of  children,  or  of  persons  greatly 


96 


THORACIC    DISEASES. 


emaciated,  the  degree  of  elacticity  is  such  as  to  render  preferable 
the  use  of  but  a  single  finger. 

Percussion  is  extensively  applicable  in  detecting  the  condition  of 
organs  both  in  the  thorax  and  in  the  abdomen.  Its  importance, 
however,  is  much  greater,  in  the  former  case  than  in  the  latter. 

The  degree  of  resonance  or  dulness  is  different  in  different  por- 
tions of  the  body,  while  in  health.  In  the  abdomen,  the  alimen- 
tary canal  is  ordinarily  distended  partly  with  gaseous  substances ; 
and,  hence,  percussion  directly  over  this  canal  gives  considerable 
resonance.  On  the  other  hand,  over  the  solid  viscera, — over  the 
liver,  for  instance, — we  get  a  degree  of  dulness. 

In  the  thorax,  the  resonance,  cceteris  paribus,  is  greatest  over 
those  portions  of  the  lungs,  in  which  the  vesicles  and  smallest 
bronchial  tubes  are  most  numerous,  because  the  thin  parietes  of 
those  cells  and  tubes  favor  the  vibration  of  air  within  them ;  while, 
on  the  other  hand,  the  thick  and  rigid  walls  of  the  large  bronchi- 
al tubes  allow  of  comparatively  little  vibration,  and  render,  in  per- 
cussion, a  degree  of  dulness.  The  sound,  however,  is  very  much 
modified  by  the  character  of  the  parietes  of  that  part  of  the  tho- 
rax on  which  we  percuss.  Thickness  of  muscular,  adipose,  or 
osseous  substance  creates  dulness.  The  heart  is  a  substance  much 
more  solid  than  the  lungs.  Hence  percussion  on  the  prascordia 
gives  a  duller  sound  than  over  any  portion  of  the  lungs. 

In  general,  the  resonance,  the  thoracic  viscera  being  normal,  is 
greatest  in  the  axillas,  on  the  sides,  along  the  lower  part  of  the  an- 
terior margin  of  the  chest,  and  below  the  scapulas,  posteriorly; 
while,  at  the  summit  and  at  the  root  of  the  lungs,  the  sound  is 
comparatively  dull.  Where  a  portion  of  the  left  lung  overlaps  the 
heart,  the  sound,  of  course,  is  intermediate  between  the  natural 
dulness  at  the  centre  of  the  prascordia,  arid  the  resonance  where 
the  vesicles  are  most  abundant. 

In  judging  whether  there  is  disease  of  any  viscus,  we  compare, 
in  our  minds,  the  sounds  heard  with  such  as  we  believe  health 
ought  to  render.  Where,  too,  there  are  analogous  parts,  we  direct- 
ly compare  the  sound  of  one  part  with  that  of  the  other. 


AUSCULTATION.  97 


CHAPTER  IX. 

AUSCULTATION. 

The  most  important  of  all  the  means  of  physical  diagnosis  is 
auscultation.  By  this  is  meant  the  art  of  detecting  the  condition 
of  internal  organs  by  means  of  the  sounds  produced  by  vital  in- 
ternal movements.  It  was  invented  by  Laennec.  Any  organ, 
which,  in  either  of  the  grand  cavities  of  the  body,  yields  a  sound, 
when  the  purposes  of  the  vital  economy  are  being  fulfilled,  may 
be  examined  by  auscultation  ;  and,  by  the  existence  and  the  qual- 
ity of  the  sound,  knowledge  is  often  gained  respecting  the  healthy 
or  the  diseased  condition  of  that  organ. 

In  regard  to  the  abdomen,  however,  this  art  is  of  less  practical 
value  than  percussion.  The  sound  of  the  foetal  heart  in  an  ad- 
vanced state  of  pregnancy  may  be  recognized  by  auscultation. 
So,  too,  may  a  peculiar  thrill  of  the  larger  arteries ;  and  certain 
intestinal  movements  in  the  abdomen  give  evidence  of  peculiar 
internal  conditions.  But  it  is  to  the  viscera  of  the  thorax  that  it 
principally  applies.  By  it  various  conditions  of  the  lungs  and  of 
the  heart  are  determined  with  much  accuracy.  These,  in  subse- 
quent pages,  are  to  be  made  the  subject  of  careful  and  extended 
remarks. 


SECTION  I. 
THE    MODE    OF    APPLYING    AUSCULTATION. 

Auscultation  is  either  mediate  or  immediate.  Mediate  auscul- 
tation supposes,  for  the  purpose  of  conveying  the  sound,  the  in- 
tervention of  a  tube  between  the  part  of  the  patient  to  be  auscul- 
ted  and  the  ear  of  the  auscultator.  Immediate  auscultation,  on 
the  contrary,  supposes  the  ear  to  be  applied  directly  to  the  part  to 
be  examined. 

Laennec  employed  mediate  auscultation.  Having,  accidentally, 
in  a  sense,  rolled  a  piece  of  paper  into  the  form  of  a  cylinder  and 
applied  it  to  the  chest  of  a  person  whose  heart  was  diseased,  he 
13 


98  THORACIC    DISEASES. 

was  struck  with  the  distinctness  of  the  cardiac  sound ;  and  this 
gave  origin  to  the  systematic  use  of  an  acoustic  instrument,  which 
took  the  name  stethoscope,  from  its  being  primarily  and  princi- 
pally applied  to  examinations  of  thoracic  viscera. 

Since  the  first  adoption  of  mediate  percussion,  stethoscopes  of 
various  materials  and  various  forms  have  been  employed.  The 
kind  of  instrument  originally  used  by  Laennec  was  crude  and  un- 
wieldly,  and,  with  great  propriety,  has  been  laid  entirely  aside. 

The  sounds  to  be  communicated  to  the  ear  are  variously  crea- 
ted, and  require  a  somewhat  peculiar  instrument  of  conduction. 
Those  originating  in  solids  are  best  transmitted  by  a  solid ;  and 
those  originating  in  air  are  best  transmitted  by  air.  Indeed,  the 
more  nearly  the  conducting  substance  agrees,  in  density  and  struc- 
ture, with  that  giving  origin  to  the  sound,  the  better  is  the  sound 
conducted. 

For  a  stethoscope,  then,  we  want  a  substance  which  will 
convey  sounds  such  as  are  generated  by  the  solids  within  the 
cavities  of  the  human  body,  particularly  those  within  the  tho- 
rax. This  purpose  may  be  tolerably  well  secured  by  any  one  of 
several  different  kinds  of  material  •  but  by  no  one  better,  perhaps, 
than  by  some  wood,  of  a  light  kind  but  having  firm  longitudinal 
fibres.  Cedar,  hard  pine,  mahogany,  &c.,  answer  very  well;  but 
none  is  better  than  the  first-named. 

But  several  of  the  most  important  sounds  to  be  regarded  in  aus- 
cultation, are  made  in  air,  and  therefore  require  an  aerial  conduc- 
tor ;  that  is,  they  must  be  conveyed  through  a  column  of  air.  To 
secure  this  object,  a  cylinder  is  perforated  from  one  extremity  to 
the  other  so  as  to  give  a  calibre  of  about  one  fourth  of  an  inch  in 
diameter.  The  column  of  air  rising  in  this  will  conduct  aerial 
sounds,  such  as  those  created  in  the  thorax,  by  the  respiration, 
the  voice,  and  the  cough. 

One  extremity,  however,  of  a  calibre  of  the  above-named  size 
can  come  in  contact,  at  any  one  time,  with  only  a  very  small  spot 
of  surface,  and,  consequently,  can  successfully  transmit  those 
sounds  only  which  are  produced  at  or  near  that  point  of  contact. 
This  limitation,  on  condition  that  the  sound  is  distinctly  audible, 
secures  an  advantage  in  not  allowing  different  sounds  from  an 
extended  space  to  reach  the  ear  simultaneously.  For  ordinary 


AUSCULTATION.  99 

purposes,  however,  such  a  cylinder  would  be  very  imperfectly 
adapted.  Beside  increasing  the  labor  of  examining  a  surface  of 
any  extent,  there  cannot  be  received  into  such  a  calibre  a  suffi- 
ciency of  vibrations  to  render  the  sound  sufficiently  audible. 

To  remedy  this  inconvenience,  the  calibre  of  the  instrument  is 
increased  at  its  basal  extremity,  so  as  to  take  a  conical  or  funnel- 
shaped  form, — the  opening  or  mouth  being  one  inch  or  more  in 
diameter.  By  this  arrangement,  all  the  vibrations  beneath  the 
whole  surface  covered  by  the  base  of  the  cone  are  concentrated, 
and  thereby  so  conducted  as  far  more  forcibly  to  impress  the  ear. 
The  sounds,  too,  are  further  increased  in  power  by  their  reflection 
from  the  walls  of  the  instrument,  whose  conical  relations,  give 
to  the  vibrations  an  onward  direction,  or  one  forming  a  less  angle 
with  the  central  axis.  Now,  though  metals,  glass,  porcelain,  &c. 
will  reflect  aerial  sounds  even  better  than  any  forms  of  wood,  yet 
such  materials  are  too  dense  to  receive  those  vibrations  which  orig- 
inate in  the  solids  under  examination,  and  are,  for  that  reason,  un- 
desirable. There  is  even  another  advantage  derivable  from  the 
use  of  light  but  rigid  wood  in  forming  the  stethoscope.  As,  on 
the  one  hand,  by  its  comparative  rigidity,  it  will  receive  the  finest 
vibrations  from  denser  substances,  and  yet,  by  its  comparative 
lightness,  will  give  extent  to  these  vibrations  and  cause  them  to 
impress  a  greater  amount  of  air;  so,  on  the  other,  it  will  receive 
the  rarer  vibrations  from  air,  condense  them,  and  transmit  them 
to  a  more  solid  substance,  or  to  the  ear.  Hence,  it  will  tolerably 
well  transmit  any  strong  vibrations  which  fall  upon  the  walls,  too 
perpendicularly  to  be  reflected  much  onward ;  and  thus  sounds  are 
so  transmitted,  by  the  walls  of  the  tube  and  by  the  contained  col- 
umn of  air,  that  a  tinkling  echo,  which  would  otherwise  mask 
the  original  character,  is  avoided. 

To  complete  the  acoustic  instrument,  it  should  be  furnished, 
at  the  extremity  which  is  at  or  above  the  apex  of  the  cone,  with 
an  ear-piece  essentially  flat  and  of  such  size  as  to  adapt  itself  well 
to  the  auscultator's  ear,  varying  somewhat,  of  course,  according 
to  the  shape  and  size  of  that  ear.  Or  he  may  have  the  extremity 
form  a  nipple-shaped  projection;  and,  by  inserting  that  directly 
into  the  organ  of  hearing,  thus  secure  the  whole  sound.  A  prop- 
er length  for  the  cylinder  is  about  six  inches.  Tt  should  not  be 


100  THORACIC    DISEASES. 

so  short  as  to  endanger  a  reception  of  sound  passing  to  the  ear 
without  the  instrument,  nor  yet  so  long  as  very  much  to  dimmish 
the  intensity  of  the  sound  which  it  transmits. 

A  stethoscope,  consisting  of  a  flexible  tube  about  two  feet  in 
length,  and  having  a  calibre  of  the  ordinary  size,  has  sometimes 
been  employed.  This,  like  the  one  in  more  common  use,  is  fur- 
nished, at  one  extremity,  with  a  funnel-shaped  opening,  and,  at 
the  other,  with  an  ear-piece.  It  was  first  introduced,  by  Dr.  Pen- 
nock  of  Philadelphia,  for  the  purpose,  more  particularly,  of  ex- 
amining the  sounds  of  the  heart ;  because  it  would  convey  the 
vibrations  to  the  ear,  without  giving  an  impression  of  the  impul- 
sion against  the  walls  of  the  thorax.  I  have  frequently  employed 
it,  with  good  effect,  in  ausculting,  not  only  the  heart,  but  the 
lungs.  Tt  affords  one  advantage  in  the  examination  of  a  person 
who  is  too  feeble  to  be  raised  into  the  upright  posture.  You  may 
sit  or  stand  by  his  bed,  and  the  length  of  the  instrument  will  en- 
able you  to  make  any  wished-for  application. 

One  other  kind  of  stethoscope  remains  to  be  considered.  It 
has  been  introduced  by  doctors  Camman  and  Clark  of  New  York, 
specially  for  auscultatory  percussion.  This  instrument  consists  of 
a  cylinder,  not  perforated,  made  of  cedar  or  some  similar  kind  of 
wood,  about  six  inches  in  length,  and  three  fourths  of  an  inch  in 
diameter,  and  furnished,  as  usual,  with  an  ear-piece.  It  is  appli- 
cable to  any  case  in  which  we  would  detect  the  dimensions  of  a 
solid  viscus  or  tumor  in  either  of  the  large  cavities  of  the  body. 
Its  principal  use,  however,  is  in  ascertaining  the  dimensions  of 
the  heart,  including  its  investing  membrane,  the  pericardium. 
Sometimes  a  parabolic  or  wedge-shaped  form  is  given  to  the  ex- 
tremity to  be  applied  to  the  patient,  in  order  to  adapt  it  to  the  in- 
tercostal depressions  of  the  prsecordia. 

In  auscultatory  percussion,  we  place  the  solid  stethoscope 
somewhat  centrally  over  the  organ  to  be  examined,  and  apply  the 
ear,  as  in  other  cases,  supporting  the  instrument  by  the  ear.  We 
then  percuss,  as  usual,  over  the  organ  and  near  its  border;  and, 
gradually  moving  the  pleximeter,  we  continue  the  percussion,  un- 
til the  line  of  the  margin  is  indicated  by  a  change  of  sound. 
While  percussing  over  any  organ,  as  the  heart,  for  instance,  and 
near  the  stethoscope,  we  hoar  "a  clear,  sudden,  intense  sound  of 


AUSCULTATION.  101 

a  high  tone  ;"  and  this  is  accompanied  with  a  short  abrupt  impulse 
apparently  produced  directly  under  or  within  the  instrument.  If 
we  strike  a  little  remote,  where  the  lungs  overlay  the  heart,  we 
have  a  mixed  sound  or  one  somewhat  modified,  but  retaining  in 
part  its  cardiac  type.  But,  moving  the  pleximeter,  by  degrees, 
still  farther,  as  soon  as  we  pass  entirely  from  over  the  heart,  the 
sound  suddenly  changes,  "losing  its  intensity  and  high  tone,  and 
being  no  longer  impulsive,  but  grave  and  distant." 

In  the  same  manner  we  may  explore  the  boundaries  of  the 
liver.  The  stethoscope  being  centrally  placed,  the  sound  pro- 
duced near  it  will  be  somewhat  clear  and  intense,  and  seem  to  be 
directly  under  the  instrument,  though  more  prolonged  and  rever- 
berant than  in  the  case  of  the  heart.  As  we  pass  from  the  instru- 
ment, the  sound  diminishes,  and  is  lost  as  soon  as  we  get  beyond 
the  hepatic  margin. 

Auscultatory  percussion  may  be  applied  to  the  spleen,  the  kid- 
neys, aneurisms,  and  internal  tumors.  It  is  supposed,  also,  that, 
by  it,  fractures  of  bones  may  be  detected,  and  that  true  anchylo- 
sis may  be  discriminated  from  false.  Where  the  parts  are  contin- 
uous and  united,  "the  sound  and  impulse  are  transmitted;"  but, 
where  the  parts  are  separated,  the  sound  and  impulse  scarcely 
appear. 

That  this  mode  of  detecting  disease  may  be  made  of  some 
further  utility  is  probable  enough.  Still,  with  the  benefit  of  the 
more  common  means  of  physical  diagnosis,  it  is  hardly  to  be  ex- 
pected, that  the  province  of  auscultatory  percussion  will  be  very 
much  extended. 

Mediate  auscultation  and  immediate  have  each  its  advantages. 
The  advantages  of  the  former  are  principally  the  following. — By 
the  stethoscope,  especially  by  one  whose  funnel-shaped  portion  is 
contracted,  we  can,  with  precision,  determine  the  point  from  which 
an  internal  sound  originates.  We  can  accurately  mark,  for  in- 
stance, the  position  of  a  pulmonary  cavity,  and  can  discriminate 
from  which  of  the  cardiac  orifices  a  morbid  sound  of  the  heart 
proceeds;  whereas,  by  the  ear  directly  applied  to  the  thorax,  we 
gather  the  sound  from  so  large  a  space,  that  as  nice  discrimination 
is  impossible.  We  may  hear  several  modifications  of  sound, 
arising  from  points  a  little  remote  from  each  other,  but  confusedly 


102  THORACIC    DISEASES. 

mingled.  There  is  even  a  liability  of  our  mistaking  tracheal  res- 
piration, conveyed  to  the  ear  by  the  surface  of  the  head,  for  cav- 
ernous respiration  in  the  superior  lobe  of  the  lung,  over  which 
the  ear  is  placed.  Another  advantage  is  in  the  better  application 
of  the  stethoscope  than  of  the  ear,  to  some  portions  of  the  body,  as 
the  axillae,  the  spaces  between  the  scapulae,  and  the  post-clavicu- 
lar regions,  in  cases,  especially,  of  emaciation  and  depression. 
Again,  in  the  case  of  the  female,  modesty  sometimes  requires  the 
application  of  the  stethoscope,  in  ausculting  the  mammary  region. 
And,  still  further,  the  immediate  application  of  the  ear  to  any 
portion  of  the  body,  when  the  patient  is  filthy,  especially  if  freely 
perspiring,  is  not  pleasant ;  and,  if  he  happens  to  be  afflicted  with 
an  infectious  disorder  or  with  certain  nameless  specimens  of  ani- 
mal life,  it  is  neither  pleasant  nor  safe. 

On  the  other  hand,  immediate  auscultation  is  more  simple,  more 
easily  adopted,  and  more  readily  learnt.  If  the  stethoscope  is 
employed,  it  must  be  so  adjusted  as  to  have  a  perfect  contact  with 
the  surface  to  which  it  is  applied  ;  and  the  ear  must  be  carefully 
adapted  to  the  ear-piece.  In  immediate  auscultation  there  is  noth- 
ing of  this  sort  to  require  attention.  The  sounds,  too,  appear 
louder,  and  better  characterized  than  when  the  stethoscope  is  em- 
ployed. The  reason  is,  vibrations,  in  greater  amount,  enter  the 
ear,  being  conducted  to  it,  by  the  solids  of  the  patient's  body  and 
the  auscultator7s  head.  This,  in  ausculting  the  chest  of  a  person 
whose  respiration  is  feeble,  or,  in  any  case  in  which  the  sounds 
lack  distinctness,  is  of  no  small  advantage.  When  the  stethoscope 
is  used,  there  is  more  danger  of  mistaking  a  rustling  of  the  pa- 
tient's clothes  or  other  external  noise,  for  a  sound  rendered  through 
the  instrument.  More  care,  too,  needs  be  taken  in  assuming  an 
unconstrained  position,  and  in  having  the  part  to  be  examined 
nearly  or  altogether  divested  of  covering.  In  immediate  auscul- 
tation, unless  the  case  be  one  demanding  niceness  of  discrimina- 
tion, these  particulars  need  not  be  as  closely  regarded. 

Again,  in  a  large  majority  of  cases,  the  direct  application  of 
the  ear  is  decidedly  to  be  preferred,  on  account  of  the  greater 
rapidity  of  its  application.  Not  only  is  there  no  delay  by  reason 
of  the  absence  of  the  stethoscope,  but  the  ear  can  be  passed  much 
more  rapidly,  and  yet  ordinarily  as  successfully,  over  the  part  to 


AUSCULTATION.  103 

be  ausculted.  As  we  gather  the  sound  from  a  considerable  sur- 
face at  once,  we  can  make  each  successive  application  at  a  point 
more  remote  from  the  preceding,  in  passing  over  those  parts  where 
there  is  nothing  abnormal  or  what  requires  special  attention. 


SECTION    II. 
THE    HEALTHY    SOUNDS    OF    RESPIRATION. 

Healthy  respiration  has  two  elements  of  sound. 

1st,  The  tubal  or  bronchial  sound. 

2d,  The  vesicular  sound, — sometimes  called  the  vesicular  mur- 
mur, or  vesicular  respiration. 

In  health,  these  sounds,  in  inspiration,  are  always  combined, 
but  in  different  proportions.  In  some  diseases,  however,  the  for- 
mer may  be  heard  without  the  latter;  but  the  latter  must  always 
be  more  or  less  modified  by  the  former.  In  expiration  the  sound, 
in  health,  is  in  a  good  degree  bronchial,  being  modified  compara- 
tively little  by  vesicular  influence. 

The  better  to  illustrate  the  character  of  these  sounds  or  ele- 
ments of  sound,  I  present,  in  few  words,  some  matters  connected 
with  the  anatomy  of  the  parts  concerned  in  their  formation.  The 
great  mass  of  each  lobe  of  the  lungs  is  filled  with  air-cells  or 
vesicles ;  but  these  are  divided  into  clusters,  and  each  cluster, 
with  the  tissues  involved,  is  called  a  lobule.  Each  lobule  is  com- 
pletely separated,  from  those  by  which  it  is  surrounded,  by  areolar 
tissue. 

The  large  bronchi  or  bronchial  tubes,  forming  the  bifurcation 
of  the  trachea,  almost  immediately  enter  the  lungs,  divide  and 
subdivide,  but  without  anastomosis,  until  they  have  sent  branches, 
that  is,  smaller  bronchi  or  bronchia  (the  latter  term  being  some- 
times employed  to  designate  the  branches  of  the  largest  tubes) 
to  every  part  of  the  organs.  There  is,  however,  a  difference  in 
the  manner  in  which  these  tubes  enter  the  lungs.  The  one  lead- 
ing to  the  right  lung  is  shorter  and  larger  than  the  one  leading  to 
the  left, — the  latter  passing  behind  the  aorta,  and  necessarily  tak- 
ing a  more  tortuous  course  than  the  former. 

"All  the  larger  branches "  of  these  tubes,  in   the  language  of 


104  THORACIC    DISEASES. 

Kirkes  and  Paget,  "have  walls  formed  of  tough  membrane,  with 
organic-muscular  circular  fibres,  giving  them  some  power  of  spon- 
taneous contraction, — portions  of  cartilaginous  rings,  by  which 
they  are  held  open, — and  longitudinal  bundles  of  elastic  tissue, 
for  greater  power  of  recoil  after  expansion.  They  are  lined  with 
mucous  membrane,  the  surface  of  which  is  covered  with  vibratile 
ciliary  epithelium.  But,  when  the  bronchi,  by  successive  branch- 
ings, are  reduced  to  about  1-100  of  an  inch  in  diameter,  they  lose 
these  structures,  and  their  walls  are  formed  of  only  a  tough,  elas- 
tic membrane,  with  traces  of  fibrous,  perhaps  muscular  structure, 
over 'which  the  capillaries  are  spread  in  a  very  dense  network,  and 
on  various  parts  of  which  air-cells  irregularly  open.  Tubes  of 
this  kind  are  named,  by  Mr.  Rainey  intercellular  passages.  The 
air-cells,  opening  into  them,  may  be  placed  singly  on  their  walls, 
like  recesses  from  them ;  but  more  often  are  arranged  in  rows, 
like  minute  saculated  tubes  ;  so  that  a  succession  or  series  of  cells, 
all  opening  into  one  another,  open  by  a  common  orifice  into  the 
tube."  Each  lobule  has  one  small  bronchus  or  bronchium  of  its 
own.  This  terminal  bronchus  passes  directly  to  the  centre  of 
the  lobule,  and  there  terminates  in  a  slight  enlargement  so  as  to 
be  fitly  compared,  on  a  reduced  scale,  to  a  pipe-stem  with  a 
sponge  attached  to  it.  On  their  way  towards  their  termini,  the 
bronchi,  in  connexioa  with  blood-vessels,  pass,  in  the  areolar  tis- 
sue, between  the  lobules. 

"  The  cells  are  of  various  forms,  according  to  the  mutual  pres- 
sure to  which  they  are  subject.  Their  walls  are  nearly  in  contact, 
and  they  vary  from  1-120  to  1-1200  of  an  inch  in  diameter. 
Their  walls  are  formed  of  fine  membrane,  similar  to  that  of  the 
intercellular  passages,  and  continuous  with  it,  which  is  folded  on 
itself,  so  as  to  form  a  sharp-edged  border  at  each  circular  orifice  of 
communication  between  contiguous  air-cells3  or  between  the  cells 
and  the  bronchial  passages.  The  cells  have  no  epithelial  lining  ', 
but,  on  the  exterior  of  the  membrane  of  which  they  are  construc- 
ted, a  network  of  pulmonary  capillaries  is  spread  out  so  densely 
that  the  interspaces  or  meshes  are  even  narrower  than  the  vessels, 
which  are,  on  an  average,  1-3000  of  an  inch  in  diameter."  Each 
terminal  bronchus  is  surrounded  by  the  air-cells  of  that  lobule. 
Those  cells  in  immediate  contact  with  the  bronchus  open  directly 


AUSCULTATION.  105 

into  it.  Those  more  remote  open  only  indirectly, — that  is,  through 
those  that  are  nearer.  "  The  multitude  of  these  cells,"  says  Dr. 
Morton,  "and  the  great  space  they  must  afford,  by  their  collective 
internal  surface,  may  be,  in  some  measure,  conceived  of  from  the 
calculation  of  Rochoux,  that  the  number  of  air-cells  grouped 
around  each  terminal  bronchus  is  little  less  than  18,000,  and  that 
the  total  number  in  the  lungs  amounts  to  six  hundred  millions." 
From  this  construction  of  each  lobule  it  is  seen,  that  the  passage 
of  air  through  any  terminal  bronchus  must  distend  the  air-cells 
connected  with  that  bronchus,  not  simultaneously,  but  in  quick 
succession. 

The  first  element  of  healthy  respiration,  then,  called  the  tubal 
or  bronchial  sound,  is  made  by  the  passage  of  air  through  the 
bronchial  tubes.  It  is  a  clear  blowing  sound,  somewhat  resem- 
bling what  may  be  made  in  the  mouth  and  fauces,  by  quickly  in- 
haling the  air,  with  the  mouth  a  little  open.  It  is  most  distinctly 
heard  directly  over  the  large  bronchi,  at  the  root  of  the  lungs; 
but  is  appreciable,  also,  to  a  considerable  distance  from  those  parts. 
Indeed,  passing  from  the  root  of  the  lungs,  there  is  a  diminution 
of  the  bronchial  sound,  until  it  is  fully  masked  by  the  vesicular. 
This  diminution  is  measurably  uniform,  but  not  entirely.  At  the 
summit  of  the  lungs,  or  in  the  subclavicular  regions,  the  bron- 
chial character  of  the  sound  is  quite  as  evident,  as  it  is  a  little 
lower,  and  nearer  the  pulmonary  roots; — owing,  probably,  to  the 
comparative  thinness  of  the  muscular  tissue,  upon  the  superior 
portions  of  the  thorax. 

It  should,  also,  be  here  remarked,  that,  owing  to  a.n  anatomical 
fact  already  alluded  to,  the  bronchial  sound,  both  anteriorly  and 
posteriorly,  is  sometimes  appreciably  louder,  on  the  right,  than  on 
the  left  side. 

This  sound,  though  purer,  or  less  modified  by  the  second,  in 
expiration  than  in  inspiration,  is  yet  feebler  in  the  former  case 
than  in  the  latter.  Indeed,  the  act  of  expiration  is  usually,  in 
health,  considerably  shorter  than  that  of  inspiration;  the  former 
being  variously  estimated  as  one  fifth,  one  third,  and  one  half  of 
the  latter, — the  last  estimate,  however,  being  evidently  the  near- 
est to  the  truth.  And,  while  the  act  itself  is  shorter,  the  sound 
generally  ceases  to  be  audible  before  the  expiration  is  closed. 
14 


106  THORACIC    DISEASES. 

Some  have  considered,  that  the  original  seat  of  the  bronchial 
sound  is  in  the  fauces  and  nasal  cavities,  and  that  it  is  little  more 
than  conveyed  by  the  bronchial  tubes  to  the  part  over  which  it  is 
heard.  This,  however,  is  clearly  an  error.  We  know,  from  the 
nature  of  wind  instruments,  and  from  the  effect  of  blowing  strong- 
ly into  any  tube,  that  sound  is  produced  in  every  part  of  the  cal- 
ibre ;  and  so  it  must  be  with  the  air  passages.  The  quality  of 
the  sound,  however,  is  given  by  the  size  of  the  calibre  and  other 
conditions.  Hence,  the  same  current  of  air  which,  at  length, 
enters  the  bronchial  tubes,  to  produce  a  sound  there,  produces, 
while  passing  through  the  trachea,  a  fuller  and  coarser  sound,  to 
which  we  give  the  name  tracheal  respiration ;  but  tracheal  respir- 
ation is  not  bronchial,  nor  bronchial  tracheal. 

The  second  element  of  healthy  respiration,  called  the  vesicular 
sound,  is  made  in  the  air-cells  or  vesicles,  partly,  perhaps,  by  the 
vibration  of  the  air  in  those  cells,  but,  more  especially,  by  their 
simultaneous  and  successive  expansion.  It  is  a  gentle  breezy 
sound,  very  much  resembling  the  strong  whisper  or  breathing  out 
of  the  word  awe;  and,  on  account  of  its  character,  is  often  des- 
cribed as  a  murmur,  or  called  the  vesicular  murmur.  It  is  best 
heard,  or  is  least  masked  by  the  bronchial  sound,  over  those  por- 
tions of  the  lungs  containing  the  greatest  number  of  vesicles  and 
only  the  smallest  bronchial  tubes ;  that  is,  in  general,  the  portions 
most  remote  from  the  root  of  the  lungs,  particularly  the  base  an- 
teriorly, and  the  axillary  and  sub-axillary  portions  laterally. 

This  sound,  from  the  manner  in  which  it  is  made,  is  confined 
chiefly  to  acts  of  inspiration.  In  expiration,  the  vesicles  empty 
themselves  gradually;  and,  hence,  scarcely  give  rise  to  the  vesic- 
ular murmur.  There  is  very  little  opportunity  for  a  rustling  of 
the  air  against  the  sides  of  the  cells,  and  almost  none  for  a  crack- 
ling to  be  produced  by  the  movement  of  the  walls. 

In  the  dilatation  of  the  vesicles,  they  are  forced  open  by  the 
entering  current  of  air,  and  somehow  the  vesicular  murmur  is 
produced.  This  is  proved  by  creating  an  artificial  respiration 
with  an  animal  suddenly  killed.  As  the  air  enters  the  vesicles, 
the  murmur  may  be  distinctly  heard  ;  but  expel  the  air  from  the 
vesicles,  and  they  empty  themselves  almost  noiselessly.  In  in- 
spiration, the  vesicles  become  the  terminating  and  impinging 


AUSCULTATION.  107 

points  of  the  air.  In  expiration,  there  is  no  terminus,  but  the 
current  passes  freely  to  the  external  world.  In  the  dilatation  of 
the  vesicles,  in  inspiration,  the  pulmonary  tissues  are  moved  by 
the  mechanical  pressure  of  the  air  within, — the  parts  being  dis- 
placed, not  simultaneously,  but  as  one  tissue  crowds  upon  another. 
In  the  contraction  of  the  vesicles,  in  expiration,  probably  their 
walls  collapse  first,  and  the  outer  tissues  follow,  without  pressure 
one  upon  another. 

The  vesicular  sound  differs  in  intensity  in  different  individuals 
in  health.  As  heard  with  some,  it  is  always  feeble ;  with  others, 
it  is  comparatively  loud.  With  persons  of  a  nervous  tempera- 
ment and  consequent  rapid  respiration,  it  is  louder  than  with 
those  of  a  different  temperament,  though  more  robust  and  athletic. 
In  general,  it  is  louder  in  women  than  in  men,  and  in  children 
than  in  adults.  It  is  mainly,  indeed,  the  increased  strength  of 
the  vesicular  sound,  which  makes  a  peculiarity  of  respiration  in 
children,  and  has  given  rise  to  the  phrase  puerile  respiration,  and, 
in  disease,  to  signify  supplementary  or  increased  healthy  respira- 
tion in  one  lung,  in  consequence  of  impaired  action  on  the  part 
of  the  other.  Puerile  respiration,  however,  supposes,  to  an  ex- 
tent, an  increase  of  the  bronchial,  as  well  as  of  the  vesicular 
sound. 

In  ordinary  respiration,  the  vesicular  sound  is  never  complete, 
though  in  some  persons  it  is  nearer  so  than  in  others.  Fully  to 
dilate  the  vesicles  always  requires  a  forced  respiration  ;  but  the 
inferior  portions  of  the  lungs  call  for  a  greater  respiratory  effort, 
than  do  the  superior ;  inasmuch  as  the  bronchial  tubes,  in  the 
former  case,  have  to  pursue  a  longer  course,  and  become  more 
reduced  in  size. 

The  two  sounds  now  described,  the  tubal  or  bronchial  and  the 
vesicular,  enter  in  a  degree,  into  every  healthy  respiration ;  but 
the  vesicular  is  scarcely  observable  in  the  expiratory  act.  In  in- 
spiration, the  bronchial  sound  is  least  modified  by  the  vesicular 
directly  anterior  or  posterior  to  the  large  bronchi.  The  vesicu- 
lar, on  the  contrary,  is  least  modified  by  the  bronchial,  as  heard 
from  those  parts  of  the  thorax  most  remote  from  the  large  bron- 
chi, particularly  at  the  base  of  the  lungs,  anteriorly  and  posterior- 
ly, and  at  the  lateral  portions  of  the  thorax.  Over  the  medium-siz- 


108  THORACIC    DISEASES. 

ed  bronchial  tubes,  equally  removed  from  the  largest  and  from  the 
vesicles  at  the  extremities  of  the  smallest,  the  two  sounds  are 
mingled  the  most  equally ;  but,  in  health,  perhaps  neither  of  the 
two,  in  inspiration,  is  heard  from  any  part  of  the  lungs,  without 
being  mingled,  more  or  less,  with  the  other.  In  expiration,  how- 
ever, the  bronchial  sound  is  but  slightly  modified  by  the  vesicular. 
It  is  true,  that  it  differs,  very  appreciably,  from  the  most  marked 
form  of  bronchial  respiration  in  disease  ;  but  this,  probably,  is  to 
be  mainly  ascribed  to  the  elasticity  of  the  tubes  and  the  softness 
of  the  surrounding  pulmonary  tissue, — circumstances  very  differ- 
ent from  those  which  give  the  morbid  character  to  the  sound. 

The  bronchial  sound  of  health,  as  least  mingled  with  the  vesi- 
cular, is  very  commonly  called  the  blowing  sound.  I  usually 
describe  it,  as  the  blowing  or  healthy  bronchial  sound.  The  res- 
piration, as  heard  over  the  greater  portion  of  the  lungs  and  hav- 
ing the  vesicular  element  very  distinct,  is  often  called  the  respi- 
ratory murmur ;  but,  as  this  sound  is  limited  to  inspiration,  it  is, 
with  equal  propriety,  called  the  inspiratory  murmur. 

There  are  some  varieties  of  healthy  respiration,  which  require 
to  be  carefully  noticed.  I  have  already  spoken  of  the  respiration 
of  children,  as  being  characterized  by  an  increase  of  both  the 
healthy  sounds,  but,  especially,  the  vesicular.  This  peculiarity 
seems  to  be  owing  essentially  to  the  facts,  that  the  parietes  of  the 
thorax  with  children,  are  comparatively  thin,  and,  especially,  that 
there  is,  in  early  life,  a  greater  activity  of  the  respiratory  organs, 
by  which  the  air  is  driven  into  the  lungs  more  forcibly.  I  now 
remark,  that,  in  advanced  life,  the  respiration  becomes  more  feeble 
than  it  is  in  middle  age,  from  the  diminished  activity  of  the  vital 
functions.  The  muscles  of  respiration  have  less  energy,  and, 
probably,  the  pulmonary  tissues  themselves  are  less  susceptible  of 
vigorous  action.  This  diminution  of  force  characterizes  both 
sounds  ;  but  is  quite  as  perceptible  in  the  bronchial  as  in  the 
vesicular. 

There  are  other  varieties  dependent  on  the  peculiarities  of 
physical  developement.  In  corpulent  persons,  the  temperament 
and  other  conditions  being  equal,  the  respiration,  as  heard,  is 
more  feeble,  the  adipose  matter  of  the  chest  being  a  bad  con- 
ductor of  sound.  The  serous  infiltration  of  the  areolar  tissue, 


AUSCULTATION.  109 

produced  by  disease,  may  have  the  same  effect.  The  lungs 
may  act  normally  •  but  the  sound  is  obstructed  in  passing  to  the 
ear.  In  females,  the  mammary  glands  repress  the  sounds  in  por- 
tions of  the  chest. 

There  are,  also,  varieties  dependent  on  accidental  causes,  as 
the  influence  of  digestion,  muscular  exercise,  nervous  excite- 
ment, and  -the  like  :  but  these  do  not  require  a  delineation.  The 
discriminating  judgment  and  practical  tact  of  the  experienced 
auscultator  will  be  his  best  guide. 

The  elements  of  healthy  respiration,  as  now  described,  should 
be  thoroughly  studied  by  every  one  who  desires  a  correct  knowl- 
edge of  auscultation,  or  who  designs  ever  to  practice  it.  I  would 
recommend,  to  every  learner,  to  take  frequent  opportunities  to  lis- 
ten to  the  bronchial  sound  at  the  root  of  the  lungs,  and  to  the 
vesicular,  at  the  inferior  and  lateral  portion  particularly.  I  would 
also  advise  him  to  make  his  examinations,  with  individuals  of  dif- 
ferent ages,  temperament,  and  conformations,  and  of  both  sexes. 
In  this  way,  he  will,  by  habit,  the  better  discriminate  the  radical 
features  of  the  two  sounds,  and  will  learn  to  trace  these,  amidst 
numerous  shades  of  difference  arising  from  incidental  causes. 
Having  formed,  for  himself,  an  idea  of  each  sound  as  distinct  as 
possible,  he  will  be  able  to  detect  each  element  of  respiration, 
even  where  the  sounds  are  most  equally  mingled  and  thoroughly 
blended. 

It  is  well,  too,  to  be  familiar  with  the  differences  resulting  from 
voluntarily  modifying  the  act  of  breathing.  A  protracted  and 
forced  inspiration,  by  more  thoroughly  dilating  the  air-passages, 
particularly  the  vesicles,  will  considerably  vary  the  character  of 
the  sound.  A  strong  but  short  and  hurried  breathing  will  also 
give  a  peculiarity. 

And,  finally,  one  must  accustom  himself  to  the  influence  pro- 
duced, upon  portions  of  the  lungs,  by  the  solid  viscera  in  imme- 
diate proximity.  The  heart  affects  the  sound  of  a  certain  portion 
of  the  left  lung,  and  the  liver  that  of  a  different  portion  of  the  right. 

Having  formed  a  distinct  conception  of  the  sounds  which  char- 
acterize healthy  respiration,  one  is  prepared  to  understand  the  va- 
rious departures  from  that  respiration  ;  in  other  words,  the  abnor- 
mal or  morbid  respiratory  sounds. 


110  THORACIC    DISEASES. 

SECTION  III. 
THE    DISEASED    SOUNDS    OF    RESPIRATION. 

The  diseased  sounds  of  respiration  are  made  while  the  air  is 
passing  through  portions  of  the  lungs,  and  their  character  depends 
especially  on  the  size  and  form  of  the  air-passages,  the  man- 
ner in  which  the  air  impinges  against  the  sides  and  angles  of 
those  passages,  and  on  the  circumstances  under  which  the  sounds 
are  conveyed  to  the  ear. 

These  sounds  are  variously  modified.  Those  modifications, 
however,  which  are  the  most  marked  and  which  first  demand 
our  attention,  are  the  three  following, — the  shrill  bronchial  respi- 
ration, the  cavernous,  and  the  amphoric. 

In  general,  the  shrill  bronchial  respiration  differs  from  the  blow- 
ing bronchial,  or  the  bronchial  respiration  of  health,  in  three  par- 
ticulars,— it  is  less  modified  by  the  vesicular  murmur,  it  is  louder, 
and  it  is  heard  at  parts  of  the  thorax  at  which,  in  health,  the  res- 
piration is  mainly  vesicular.  It  is  produced  by  those  diseases 
which  harden  the  parenchyma  of  the  lungs  and  block  up  or  com- 
press the  vesicles.  Of  course,  it  differs  much  less  from  the  sound 
heard  in  healthy  expiration,  than  from  that  heard  in  healthy  in- 
spiration, as  it  is  in  inspiration  only  that  the  vesicular  murmur  is 
distinctly  heard.  When  shrill  bronchial  respiration  is  perfect,  it  is 
entirely  devoid  of  the  vesicular  sound ;  that  is,  it  is  perfectly 
tubal.  When  the  vesicles  are  in  a  condition  partially  to  receive 
the  air,  the  shrill  or  diseased  bronchial  respiration  is  imperfect, 
and  is  sometimes  called  rude  respiration. 

The  increased  loudness  of  the  shrill  bronchial  sound  is  merely 
the  result  of  a  more  perfect  conveyance  to  the  ear,  by  means  of 
hardened  tissue.  If  the  induration  immediately  around  the 
larger  bronchi  be  considerable,  the  shrill  tubal  sound  will  be 
louder,  than  when  those  portions  of  the  lungs  in  which  exist  only 
the  vesicles  and  smaller  tubes,  are  the  seat  of  the  disease.  The 
reason  is  obvious.  The  larger  bronchi  are  mainly  concerned  in 
giving  origin  to  the  bronchial  sound.  Of  course,  the  conducting 
medium  being  the  same,  a  greater  sound  will  reach  the  ear,  im- 
mediately over  those  tubes,  than  at  a  distance. 


AUSCULTATION.  Ill 

But  the  shrill  bronchial  sound  is  very  commonly  heard,  in  cer- 
tain diseases  where  in  health  the  vesicular  murmur  is  most  mark- 
ed. This  is  because  the  induration,  obliterating  the  vesicles,  pre- 
vents the  vesicular  murmur,  while  it,  at  the  same  time,  conducts 
the  tubal  sound  more  perfectly  than  does  the  spongy  tissue  of 
health.  Perhaps  one  other  circumstance  contributes  to  this  result. 
The  smaller  tubes,  as  well  as  the  vesicles,  may  become  obliterat- 
ed by  the  hardening  of  the  pulmonary  tissue.  In  that  case,  the 
air  is  suddenly  arrested  in  its  passage,  and  impinges  against  the 
walls  of  the  tubes  more  forcibly,  so  as  to  create  a  greater  tubal 
sound.  In  a  case  like  this,  bronchial  respiration  may  be  even 
louder  in  remote  parts  of  the  lungs,  than  is  the  healthy  bronchial 
sound  immediately  over  the  largest  bronchi. 

The  disease  most  fully  developing  the  shrill  bronchial  respiration 
is  pneumonatis  in  the  stage  of  hepatization.  Tubercles,  however, 
in  the  second  stage,  often  produce,  under  a  limited  surface,  a 
marked  instance  of  this  form  of  respiration.  Pleuritis,  in  the 
stage  of  effusion,  may  so  compress  the  lung  as  to  render  the  bron- 
chial sound  considerably  shrill.  Scirrhus,  too,  or  other  abnormal 
deposits,  may  have  to  some  extent,  the  same  effect. 

The  cavernous  respiration,  as  the  term  implies,  is  the  sound 
produced  by  the  passage  of  air  into  a  cavity.  This  sound,  in 
quality,  very  much  resembles  trachea  respiration.  Until  it  has 
been  heard,  the  best  idea  of  it  can  be  gained,  by  listening,  though 
the  medium  of  the  stethoscope,  to  the  sound  in  the  trachea.  The 
principal  difference,  between  tracheal  and  cavernous  respiration, 
consists  in  the  different  lengths  of  the  sounds.  In  a  cavity,  the 
current  of  air,  admitted  in  inspiration,  is  suddenly  arrested,  whirl- 
ed around  for  a  moment,  and  then  forcibly  expelled.  This  gives 
a  degree  of  abruptness  to  the  sound.  In  the  trachea,  the  inhal- 
ing effort  forces  the  air  along,  in  one  direction  and  in  a  steady 
current,  till  the  close  of  the  act.  This  renders  the  sound  rather 
more  prolonged  than  that  which  is  heard  in  a  cavity.  Should  an 
unpracticed  ear,  however,  be  unable  to  discriminate,  with  sufficient 
accuracy,  between  the  character  of  the  cavernous  and  that  of  the 
shrill  bronchial  sound,  he  will  be  aided  in  arriving  at  a  correct 

>  O 

conclusion,  by  considering  that  cavernous  respiration  is  limited  to 
a  very  circumscribed   portion  .of  the  lung,   while  the  shrill  bron- 


THORACIC    DISEASES. 

chial,  if  marked,  is  always  more  extensive,  being  limited  only  by 
the  extent  of  the  indurated  portion  of  the  pulmonary  tissue. 
The  line  of  demarcation,  too,  between  the  hardened  and  the 
healthy  portions  is  not  so  distinctly  drawn  as  are  the  walls  of  a 
cavity.  Hence,  in  an  examination  of  different  points,  with  a 
stethoscope  especially,  we  find  the  shrill  bronchial  sound  losing 
its  distinctive  character  less  abruptly,  than  the  cavernous. 

Not  all  cavities  produce  a  distinct  cavernous  respiration.  One 
about  the  size  of  a  walnut,  communicating  freely  with  some  of 
the  larger  bronchial  tubes,  and  having  firmer  walls  of  indurated 
parenchyma,  gives  the  sound  in  its  most  perfect  character.  If 
the  cavity  is  larger,  the  air  reverberates  less  fully ;  and,  if  the 
surrounding  tissue  is  measurably  permeable  to  the  air,  it  con- 
ducts the  sound  less  perfectly.  When  a  tuberculous  cavity  has 
been  of  long  standing  and  is  much  enlarged,  it  will  often  render 
but  a  very  indistinct  cavernous  sound.  In  such  a  case,  the  most 
hardened  portion  of  the  walls  is  doubtless  ulcerated  away ;  and 
it  may  sometimes  happen,  that  the  tubes  opening  into  the  cavity 
become  contracted  or  otherwise  obstructed. 

By  far  the  most  frequent  cause  of  the  existence  of  pulmonary 
cavities  is  tuberculous  disease.  They  sometimes,  however,  result 
from  the  ulceration  of  pneumonitis  in  its  last  stage,  and  from  the 
sloughing  of  mortification.  There  may,  also,  be  a  dilatation  of 
the  bronchial  tubes  of  such  extent  as  to  give,  to  the  respiration,  a 
cavernous  character  ;  but,  in  this  case,  the  sound  is  more  exactly 
like  that  of  tracheal  respiration,  as  the  air  pursues  its  onward 
course  and  is  not  reflected  as  in  other  cavities. 

Amphoric  respiration  is  really  but  a  modification  of  cavernous. 
The  sound,  however,  is  peculiar,  and,  therefore,  demands  consid- 
eration under  a  distinct  name.  It  is  derived  from  a  word  in  the 
Latin  language,  or  a  similar  one  in  the  Greek,  signifying  a  firkin 
or  large  measure.  Hence  the  phrase,  amphoric  respiration,  indi- 
cates a  sound  made  in  a  cavity  occupying  considerable  space  ;  but 
the  conditions  necessary  to  its  full  development  arc,  not  only 
largeness  of  extent  in  the  cavity,  but  the  existence  of  firm,  tense, 
and  elastic  walls.  The  proper  amphoric  respii^tion  is  a  clear  and 
ringing  sound,  and  may  be  imitated  by  blowing  into  an  empty 
flask,  a  large  glass  vial,  or  even  a  metallic  vessel.  The  best  imj- 


AUSCULTATION.  113 

tation,  however,  is  obtained,  by  pressing  one  extremity  of  a  com- 
mon lamp  chimney  upon  the  palm  of  one  hand,  and  then  resting 
the  back  of  that  hand  on  the  ear,  while  another  person  breathes 
forcibly  into  the  other  extremity  of  the  chimuey.  If  the  cavity 
giving  rise  to  the  amphoric  sound  has  a  free  communication  with 
the  bronchial  tubes,  the  peculiar  ring  will  be  heard  in  both  inspi- 
ration and  expiration  ;  but,  if  this  communication  is  so  interrupted 
that  the  air  is  discharged  but  slowly,  the  expiration  will  be  at- 
tended with  but  little  sound  and  that  not  distinctive. 

Amphoric  respiration  is  most  commonly  produced  in  a  tubercu- 
lous "cavity,  under  the  conditions  already  named.  A  gangrenous 
cavity,  however,  may  produce  it,  in  a  degree  ;  but  the  surround- 
ing tissue,  in  this  case,  is  generally  too  soft  to  render  the  peculi- 
arity very  marked.  The  amphoric  sound  is  said  to  have  been 
heard  in  cavities  created  by  pneumonitis  ;  but  the  cases  in  which 
its  character  is  very  appreciable,  must,  I  am  sure,  be  exceedingly 
rare.  The  most  marked  degree  of  the  peculiarity  is  in  pneumo- 
thorax.  In  this  case  the  pleural  sac  becomes  the  cavity,  and 
there  is  a  perforation  or  fistulous  opening  into  it  from  the  air-pas- 
sages. The  cavity  is,  of  course,  large,  and  its  walls  are  suffi- 
ciently firm,  tense,  and  elastic. 

There  are  some  other  varieties  of  respiration  which  deserve  a 
passing  notice.  Among  these,  the  most  important  is  the  rude 
bronchial  respiration.  I  use  this  term,  not  to  denote  merely  an 
imperfect  form  of  the  shrill  bronchial  sound,  or  to  imply,  simply 
that  the  vesicular  murmur  is  somewhat,  though  feebly,  heard, 
modifying  the  bronchial  sound.  I  use  it  rather  to  denote  a  rough 
or  husky  sound.  It  is  not  distinctly  tubal,  like  the  shrill  bron- 
chial, nor  having  the  breezy  smoothness  of  the  vesicular.  It  is 
probably  made  by  the  action  of  small  fibrilla  in  the  air-tubes, 
while,  it  may  be,  that  the  calibre  of  the  tubes  themselves  is 
somewhat  reduced,  either  by  the  existence  of  incipient  tubercles 
pressing  on  the  tubes,  or  by  the  thickness  of  their  coats  in  in- 
flammation. 

I  am  not,  however,  indeed,  fully  satisfied  as  to  the  pathological 

condition  which  gives  rise  to  this  sound.     I  have  heard  it  in  the 

% 

most  marked  form,  in  connexion  with  a  degree  of  chronic  hoarse- 
ness, and  a  chronic  cough,  which  by  some  would  be  termed  ner- 

15 


114  THORACIC    DISEASES. 

vous.  In  this  case,  there  was,  at  the  same  time,  considerable 
evidence,  that  incipient  tubercles  pervaded  the  lungs.  On  the 
whole,  my  impression  is,  that  the  condition  of  the  tubes  approxi- 
mates that  which  produces  the  sonorous  rale,  yet  to  be  consider- 
ed and  heard  particularly  in  acute  bronchitis.  The  peculiarity 
of  the  patient's  constitution,  in  connexion  with  the  diseased 
condition  of  the  pulmonary  parenchyma  and  of  the  membranes 
of  the  tubes,  may  cause  a  viscid  and  delicate  secretion,  which,  by 
its  dryness,  takes  on  a  fibrillous  or  ciliated  form.  If  so,  the  pe- 
culiarity of  the  sound  would,  in  strictness,  rank  it  with  the  rales ; 
but  it  is  so  slight  a  modification  of  the  respiration  as  scarcely  to 
merit  a  consideration  with  that  important  class  of  sounds.  At 
any  rate,  the  sound  is  worthy  of  the  further  consideration  of 
pathologists. 

Another  variety  of  respiration  is  the  interrupted  or  jerking. 
In  this,  the  air  seems  to  be  measurably  arrested  in  the  tubes,  for 
an  instant,  before  it  passes  on  to  the  vesicles.  The  quantity  of 
the  sound  is  essentially  normal ;  and  the  respiration  takes  its 
name  solely  from  the  broken  manner  in  which  the  air  passes. 

It  arises  from  different  causes.  In  a  nervous  sensitive  patient, 
jt  is  often  produced  by  spasm,  under  the  influence  of  excitement. 
In  bronchitis,  a  thickening  of  the  walls  of  the  smaller  tubes,  by 
inflammation,  may  produce  it.  So,  too,  may  simple  congestion. 
But  the  most  serious  condition  which  ever  gives  rise  to  it,  is  a  de- 
posit of  incipient  tubercles.  This,  of  course,  limits  the  sound  to 
that  small  portion  of  the  lung  in  which  the  tuberculous  disease  is 
commencing.  It  is  a  symptom  of  but  little  importance,  except  as, 
in  this  last  instance,  it  becomes  a  sign  of  phthisis. 

Dr.  Bowditch  speaks  of  what  he  call  mucous  respiration,  and 
says  that,  in  it,  "  the  respiratory  murmur  seems  more  moist  than 
natural,  almost  enough  so  to  produce  a  crackling  rale/'  He  says, 
"it  may  be  heard,  throughout  both  lungs,  but  is  most  distinct  at 
the  lower  and  posterior  portions.''  According  to  him,  the  sound 
is  indicative  of  chronic  bronchitis ;  and  a  fit  of  coughing  will 
sometimes  so  augment  the  secretioii(  as  to  produce  the  mucous 
rale.  Though  he  speaks  of  the  existence  of  this  sound  as  a  dis- 
covery of  his  own,  and  says  he  is  not  aware,  that  "  others  have 
noticed  it,"  yet,  to  my  mind,  it  is  perfectly  clear,  that  he  attempts 


AUSCULTATION.  115 

to  describe  what  Dr.  C.  J.  B.  Williams  calls  the  sub-mucous 
rhonchus.  Dr.  W.,  having  spoken  of  the  mucous  and  gurgling 
rhonchi,  says,  "when  there  is  a  little  liquid  in  the  smaller  bronchi, 
the  bubbling  or  crackling  is  more  regular,  although  the  sound  is 
weaker,  and  is  sometimes  only  a  roughness  added  to  the  ordinary 
respiratory  murmur.  This  is  the  sub-mucous  ?-fwnchus.  It  may 
result  from  slight  degrees  of  bronchitis,  and  owes  its  importance 
only  to  its  being  permanently  present,  when  such  slight  inflamma- 
tion is  constantly  kept  up  by  the  irritation  of  adjacent  tubercles 
in  an  incipient  state."  I  am  not  aware  of  having  myself  noticed 
a  peculiarity  of  this  kind  worthy  of  any  separate  description.  It 
is  perfectly  conceivable,  however,  that  the  bronchial  tubes  may  be 
a  little  moistened  with  a  thin  or  mucous  secretion,  and  yet  the 
quantity  of  this  secretion  may  not  be  sufficient  fully  to  develope 
either  the  mucous  or  the  subcrepitant  rale.  That  the  sound, 
when  in  exists,  should  in  strictness,  be  •  classed  with  the  rales, 
rather  than  as  a  simple  sound  of  respiration,  is,  to  my  mind,  clear. 
The  peculiarity  is  evidently  produced  by  a.  slight  liquid  obstruc- 
tion, and  not  by  the  mere  force  of  the  air  striking  against  the 
walls  of  the  air-passages.  Still,  such  nicities  of  classification  are 
practically  of  but  little  importance  ;  and  thn  sound  is  so  slight  a 
change  from  the  normal  respiration,  as  hardly  to  entitle  it,  in  de- 
scription, to  the  dignity  of  a  rale. 

Beside  these  modifications  of  the  respiration,  still  others  may 
be  named.  Both  the  normal  sounds  may  be  increased,  or  they 
may  be  diminished,  without  any  other  change  of  character.  A 
portion  of  the  lungs  may  become  so  compressed  or  so  diseased, 
as  to  be  impervious  to  air,  and  incapable  of  performing  the  proper 
ollice.  In  that  case,  another  portion  will  act  with  increased  ener- 
gy, and  give  a  louder  sound  of  respiration.  Instances  of  this  are 
observed  in  pleuritic  effusions,  and  in  pneumonitis.  Even  in 
bronchitis,  there  may  be  so  much  lesion  of  the  bronchial  tubes 
as  to  obstruct  the  passage  of  air  into  one  part,  and  thereby  give 
an  increase  of  sound  in  another  part. 

Again,  the  sound  of  respiration  as  it  reaches  the  ear,  may  be 
less  than  is  normal,  in  consequence  of  disease  in  the  structure  of 
the  lungs  or  in  parts  adjacent.  In  emphysema,  for  instance,  both 
the  bronchial  and  the  vesicular  sounds  are  enfeebled.  In  bronchi- 


116  THORACIC    DISEASES. 

tis,  too,  this  sometimes  occurs.  In  phthisis,  it  is  frequently  ob- 
served in  a  portion  of  one  lung ;  but,  in  this  disease,  there  are 
usually,  perhaps  uniformly,  other  alterations  of  the  respiratory 
sounds.  In  the  second  stage  of  pleuritis,  in  hydro-thorax,  in  em- 
pyema,  or  whenever  the  pleura  contains  a  liquid  of  any  kind,  the 
respiration,  as  heard,  is  more  or  less  feeble,  partly  by  reason  of 
the  compression  of  the  bronchi  and  vesicles,  and  partly  because 
the  interposed  liquid  interrupts  the  conduction  of  the  sound  to 
the  ear. 


SECTION  IV. 
RALES. 

Rales  are  an  important  class  of  sounds,  made,  indeed,  by  the 
passing  of  air  through  air-passages,  but  yet  in  a  manner  some- 
what different  from  that  in  which  the  simple  diseased  sounds  of 
respiration  are  produced.  The  rales  always  suppose  impediments 
or  partial  obstructions  to  the  passage  of  the  air ;  and  it  is  the  re- 
sistence  met  with  which  mainly,  gives  the  modification  of  sound. 

The  term  rale  has  been  transferred  from  the  French  to  express 
an  idea  for  which  we  have  had  no  authorized  English  word 
Even  this,  in  the  original,  is  far  from  giving  the  exact  meaning. 
It  merely  signifies  a  wheezing,  or  a  rattling  in  the  throat.  Some 
pathologists  prefer  the  Latin  term  rkojichus,  which  signifies  a 
snoring  or  snorting.  The  idea  being  a  new  one,  of  course,  to  ex- 
press it,  a  new  term  must  be  adopted,  or  there  must  be  an  accom- 
modation of  an  old  one.  Either  expedient  is  well  enough ;  and 
the  term  rale,  or  rhonchus,  or  even  the  simple  English  word  rattle, 
will  convey  the  idea,  when  once  its  application  is  defined  and  un- 
derstood. I  prefer  the  term  which  I  have  adopted,  simply  be- 
cause it  is  a  monosyllable  and  easily  pronounced,  while,  ortho- 
graphically,  it  forms  its  plural  after  the  usual  English  manner. 

The  rales  are  properly  divided  into  the  dry,  and  the  moist  or 
humid.  This  distinction  is  founded  on  the  nature  of  the  impedi- 
ments which  produce  the  sounds.  These  impediments  are  either 
solid  or  liquid.  The  dry  rales  are  three, — the  sibilant  the  sono- 
rous, and  the  crackling. 


AUSCULTATION.  117 

The  sibilant  rale  is  a  musical  or  gently  whistling  sound.  It 
may  be  sufficiently  well  imitated  by  whistling  between  the  teeth, 
with  the  lips  partly  closed  or  slightly  apart.  It  is  produced  by 
the  passage  of  air  through  a  small  and  rather  circular  aperture. 
This  aperture  is  generally  formed  by  a  slight  obstruction  in  one 
of  the  smaller  tubes,  though  it  may  be  made  by  a  greater  ob- 
struction in  a  tube  of  larger  size.  The  sound  is  extremely 
moveable,  and  equally  irregular  in  the  time  of  its  reappearance. 
Heard,  at  one  point,  in  one  respiration,  in  the  next,  or  not  until 
some  subsequent  one,  it  may  be  heard  at  some  point  remote 
from  the  first.  It  exists,  both  in  respiration  and  expiration  ;  and 
from  the  situation  of  the  smaller  tubes  from  which  it  mostly 
arises,  it  is  mostly  heard  over  those  portions  of  the  thorax,  es- 
pecially the  anterior,  which  are  a  little  remote  from  the  pulmo- 
nary roots.  Under  different  circumstances,  however,  it  is  heard 
over  almost  every  portion  of  the  chest,  anterior,  posterior  and 
lateral. 

It  is  produced  in  asthma,  in  which  the  tubes  are  congested, 
and  are  constricted  by  the  spasmodic  contraction  of  their  circular 
fibres.  In  this  disease,  particularly  if  severe,  it  is  a  protracted 
sound,  heard  in  both  inspiration  and  expiration.  In  bronchitis, 
the  tubes  may  be  so  narrowed,  by  the  swelling  of  their  mucous 
and  submucous  coats,  as  to  produce  it.  In  the  third  stage  of 
phthisis,  it  is  quite  frequently  heard,  in  connexion  with  other  dis- 
eased sounds, — the  tubes  being  constricted  by  the  muco-purulent 
matter  which  passes  into  them.  In  the  latter  case,  the  sound  is 
short,  and  is  generally  heard  from  different  tubes  during  the  same 
or  successive  respirations.  It  may  be  caused,  in  different  diseases, 
by  such  an  adherence  of  viscid  mucous  to  the  walls  of  the  tubes 
as  diminishes  their  calibre. 

The  sonorous  rale  might,  with  more  special  propriety,  be  called  a 
rhonchus.  It  is  more  of  a  snoring  sound,  or  like  deep  guttural 
breathing,  than  any  of  the  other  rales.  Various  similitudes  have 
been  adopted  to  describe  it.  It  has  been  compared  to  the  sound 
of  a  bassoon,  and  to  that  of  a  bass-viol ; — to  the  cooing  of  a 
pigeon,  to  the  hum  of  insects,  to  the  sounds  produced  by  a  piece 
of  paper  fluttering  in  the  wind,  and  to  the  grating  of  a  cart-wheel 
upon  snow  in  weather  severely  cold.  But,  whatever  idea  may 


118 


THORACIC    DISEASES. 


be  formed  of  it,  from  these  and  like  comparisons,  it  is  sufficient 
to  say,  that  it  is  a  deep  cavernous  sound,  so  unlike  any  other  pro- 
duced in  the  thorax,  that  when  once  distinctly  heard,  in  its  mark- 
ed form,  it  may  ever  afterwards  be  recognized.  It,  however, 
varies  considerably  in  tone,  according  to  the  circumstances  under 
which  it  is  created.  It  is  produced  by  such  an  obstruction  as 
leaves  a  flattened  aperture.  It  is  a  vibrating  sound  ;  and  either 
the  walls  of  the  tubes  generally,  or  the  lips  of  the  aperture, 
where  the  obstruction  exists,  must  be  the  seat  of  the  vibration. 
The  latter  is  probably  the  true  explanation.  A  partial  "  swelling 
of  the  sides  of  a  tube,  particularly  at  its  bifurcation,  a  pellet  of 
tough  mucous  in  it,  or  external  pressure  on  it,"  may  give  the  prop- 
er aperture  to  produce  the  sound ;  but  then  there  must  be,  in  ad- 
dition to  the  form,  a  vibrating  surface.  I  am  of  the  opinion,  that 
a  viscid  secretion  assuming  a  fibrillate  or  stringy  character,  is  real- 
ly the  vibrating  substance,  though  it  may  be  that  the  substance 
of  the  tubes,  when  hardened  by  inflammation,  is  capable  of  vibrat- 
ing. It  is  mainly  produced  in  the  larger  bronchial  tubes,  though 
sometimes  in  those  of  medium  size.  In  the  latter  case,  the  sound 
usually  has  a  higher  note  than  in  the  former ;  though  it  would 
seem  that  the  size  of  the  aperture,  at  the  point  of  partial  obstruc- 
tion, is  principally  concerned  in  giving  key  to  the  sound.  It  is 
most  heard  both  anteriorly  and  posteriorly,  when  the  ear  is 
placed  in  most  immediate  proximity  to  the  larger  bronchi.  It  is 
well  spoken  of  as  a  fugitive  sound,  since  it  will  frequently  cease 
and  return,  so  far  as  one  tube  or  point  is  concerned,  with  almost 
every  act  of  respiration.  It  is  not,  however,  always  so  move- 
ble  ;  and  when  it  is,  it  still  may  often  be  heard  with  every  respi- 
ration, though,  successively,  from  different  points.  It  exists  with 
both  inspiration  and  expiration ;  but  is  quite  as  marked  with  the 
latter  as  with  the  former. 

The  sound  is  pathognomanic  of  bronchitis.  In  the  acute  form 
of  the  primary  disease,  it  almost  uniformly  attends  the  progres- 
sive stage.  In  the  chronic  form  it  is  not  heard.  In  many  cases 
of  secondary  bronchitis  which  attends  other  diseases,  it  is  heard. 
If  not  connected,  however,  with  any  of  the  humid  rales,  it  is  in- 
dicative of  but  a  mild  affection. 

I  have  only  to  add,  that  the  sibilant  and  sonorous  rales  now 


AUSCULTATION.  1 19 

described  are  sometimes  commingled ;  or  there  is  a  condition  of 
the  tubes  which  creates  a  sound  partaking  partly  of  each  charac- 
ter. A  sufficient  explanation  of  this  will  readily  be  suggested,  on 
recalling  to  mind  the  description  of  the  physical  cause  of  each 
sound. 

One  other  dry  rale  remains  to  be  considered.  It  is  the  crack- 
ling. So  far  as  I  know,  this  has  never,  by  pathologists,  been  par- 
ticularly described ;  and  yet  it  seems  to  me  to  be  a  peculiarity 
worthy  of  a  definite  description.  The  sound  has  generally  been 
classed  as  a  subcrepitant  rale ;  though  by  Dr.  Gerhard,  in  the 
third  edition  of  his  work  on  Diseases  of  the  Chest,  it  is  clearly 
referred  to,  under  the  designation  of  a  variety  of  the  'mucous. 
The  French,  indeed,  in  their  hospitals,  speak  of  it  as  un  craquc- 
ment,  the  crackling,  but  do  not  assign  it  a  separate  rank  among 
the  rales.  In  its  marked  character,  it  is  pathognomanic  of  phthi- 
sis ;  and  Dr.  G.  says  of  it,  "  It  is  produced  by  the  softening  of 
the  thick  pasty  matter  of  tubercle,  which  gives  a  peculiarly  dry 
and  sharp  sound." 

Though  it  merits  a  distinctive  name  as  one  of  the  rales,  yet  I 
have  with  some  hesitation,  decided  to  rank  it  with  the  dry,  rath- 
er than  with  the  humid.  The  sibilant  and  the  sonorous  are 
caused  by  a  thickening,  or  a  spasmodic  contraction  of  the  walls 
of  the  bronchial  tubes,  or  by  something  internal,  partially  block- 
ing up  the  air-passages.  Of  course,  the  parts  are,  essentially,  in 
a  dry  condition.  The  crackling  rale  of  phthisis,  however,  indicates 
the  third  stage  of  the  disease,  when  purulent  matter  is  being  dis- 
charged from  softened  tubercles.  Still  my  impression  is,  that  the 
sound  is  not  produced  exactly  as  Dr.  Gerhard  supposes,  for  I  can- 
not understand  the  rationale  of  such  a  process.  I  think,  that  as 
the  matter  of  tubercles  is  softening,  some  pasty  portions  block  up 
the  entrances  just  firmly  enough  to  be  removed  with  the  full  in- 
gress of  the  air,  and  that  the  movement  of  the  partially  dry  and 
flaky  deposits  causes  the  crackling  sound.  Or  it  may  be.  that 
the  change  which  inspiration  effects  in  the  relation  of  parts  of 
indurated  pulmonary  substance,  is  concerned  in  the  matter.  As 
the  air  passes  into  the  opening  tubercles  and  disturbs  their  walls, 
the  rubbing  of  one  part  upon  another  may  produce  a  portion  of 
the  effect.  Of  course,  so  far  as  this  is  the  case,  the  sound  should 


120  THORACIC    DISEASES. 

not  be  regarded  as  a  crackling  rale,  but  should  be  classed  with 
the  adventitious  sounds  yet  to  be  considered. 

When  pus,  in  sufficient  quantity,  is  poured  into  the  larger  bron- 
chial tubes,  it  gives  the  mucous  rale,  which  is  very  commonly 
heard,  in  connexion  with  the  crackling,  though  the  latter  may 
precede  it,  by  a  period  of  several  days,  and  afterwards  cease, 
leaving  the  mucous  increasingly  developed. 

Besides  the  sound  now  described,  there  is  a  comparatively  un- 
important one,  which  I  know  not  how  better  to  class  than  as  a 
crackling  rale.  Dr.  Gerhard,  if  I  understand  him,  speaks  of  this 
as  the  dry  or  rustling  crepitant.  He,  however,  scarcely  describes 
it,  and  says  that  it  "  is  of  very  little  value,  and  hardly  differs 
from  the  rustling  sound  of  respiration."  By  this  last  phrase,  he 
means  what  I  have  yet  to  describe  as  the  emphysematous  crack- 
ling. Dr.  C.  J.  B.  Williams,  calls  the  sound  the  dry  mucous 
rhonchus.  He  says,  "  It  is  produced  by  a  pellet  of  tough  mucous, 
obstructing  a  tube  and  yielding  to  the  air  only  in  successive  jerks, 
which  cause  a  ticking  sound,  like  that  of  a  click-wheel.  When  the 
air  is  driven  very  fast,  these,  as  is  the  case  of  other  click  sounds, 
pass  into  a  continuous  note,  and  constitute  the  sonorous  rhonchus. 
Sometimes,  again,  particularly  in  inspiration,  the  click  sound  sud- 
denly stops. — the  tough  mucous  being  forced  into  a  smaller  tube, 
which  it  completely  closes."  The  sound,  which,  however,  but 
seldom  occurs,  supposes  a  condition  of  things  somewhat  similar 
to  that  which  produces  the  sonorous  rale.  It  is  the  result  of 
chronic  bronchitis,  or  a  morbid  power  of  mucous  secretion ;  and 
can  hardly  be  confounded  with  the  tuberculous  crackling. 

The  humid  rales*  are  produced  by  the  passage  of  air  through 
a  liquid  of  some  kind,  "  forming  bubbles  of  different  sizes." 
These  bubbles  "vary  according  to  the  tenacity  of  the  fluid,  the 
size  of  the  air  passages,  and  the  greater  or  less  rapidity  with 
which  the  air  is  forced  through  those  passages."  There  are  four 
of  these  rales, — the  crepitant,  the  subcrepitant,  the  mucous,  and 
the  gurgling.  There  is,  however,  no  marked  line  of  distinction 
between  the  crepitant  and  the  subcrepitant,  nor  hardly  between 
the  subcrepitant  and  the  mucous. 

The  crepitant  rale,  in  its  most  perfect  form,  is  believed  to  be 
made  in  the  vesicles — the  very  extremities  of  the  air-passages  in 


AUSCULTATION.  121 

the  lungs ;  or,  in  these,  together  with  the  very  small  terminating 
"tubes  which  ramify  through  the  lobules."  When  the  crepitus 
is  not  quite  so  delicate,  the  sound  is  probably  produced  in  the 
small  tubes,  just  before  they  enter  the  lobules.  To  describe  this 
rale,  various  illustrations  have  been  adopted.  It  has  been  compared 
to  the  sound  produced  by  rubbing  slowly  and  firmly,  between 
the  thumb  and  finger,  a  lock  of  hair  near  the  ear;  also,  to  the 
effervescing  of  bottled  cider  or  champagne,  to  the  crackling  of 
salt,  and  to  the  successive  explosions  of  a  small  train  of  wet 
powder.  It  seems  to  be  formed  by  the  rapid  and  equable  succes- 
sion of  extremely  fine  bubbles  arising  from  the  liquid  which  trav- 
erses the  smallest  bronchi.  This  liquid  is  necessarily  thin  ;  as 
what  is  thick  and  viscid  could  hardly  pass  through  the  extremities 
of  the  tubes,  and,  especially,  would  not  readily  allow  the  passage 
of  air  in  so  delicate  a  series  of  bubbles.  Some,  however,  have 
supposed,  that  the  dilatation  of  the  vesicles,  thickened  and  stiff- 
ened by  inflammation,  assists  in  creating  the  sound..  So  far  as 
that  may  be  true,  it  would  not  come  within  the  definition  of  a 
rale.  It  would  be  an  adventitious  sound.  I  regard  the  former, 
however,  as  the  true  explanation.  The  sound  is  almost  pathog- 
riomonic  of  pneumonitis  in  its  first  stage  ;  and,  in  that  stage,  the 
secretion  into  the  air-passages  is  serous  in  character  and  thin  in 
consistency.  The  other  conditions  which  give  rise  to  it  are  con- 
ditions of  a  thin  liquid  in  the  extremities  of  the  tubes.  It  is  con- 
fined to  the  inspiration,  as,  from  the  extremities  of  the  tubes,  the 
air  is  not  pressed  outward  with  a  force  sufficient  to  create  the 
bubbles.  From  the  nature  of  the  morbid  conditions  which  give 
rise  to  it,  it  must  necessarily  exist,  mainly  at  the  inferior  and  pos- 
terior portion  of  the  lungs,  though  it  may  occur  elsewhere. 

The  sub-crepiiant  rale  is  a  coarser  and  less  regular  crepitation 
than  the  crepitant.  The  term  is  an  awkward  one  to  express  the 
idea!  It  implies  something  less  than  the  crepitant.  It  seems, 
however,  to  have  been  originally  chosen,  not  to  express  that  the 
former  sound  is  less  than  the  latter,  but  that  the  delicacy  of  crep- 
itation is  less  with  the  former  than  with  the  latter.  I  use  the 
term,  because  it  is  established  and  for  the  want  of  a  better.  The 
second  is  intermediate  between  the  crepitant  and  the  mucous 
rales,  and,  by  an  insensible  gradation,  runs  into  the  one  or  the 
16 


122  THORACIC    DISEASES. 

other,  according  to  circumstances.  It  is  made,  in  the  medium- 
sized  tubes,  by  the  bursting  of  bubbles  through  the  contained 
liquid.  The  size  of  the  tubes  renders  the  sound  coarser  than  is 
made  in  the  extremities  and  the  vesicles  ;  while  the  traversing 
liquid  being  commonly  thicker  and  more  viscid  than  is  found  in 
the  smaller  passages,  causes  the  existence  of  less  regularity  in  the 
succession  of  the  bursting  bubbles.  This  rale  is  heard  chiefly  in 
the  inspiration,  but  very  faintly  in  the  expiration.  Like  the  crep- 
itant  rale,  it  exists,  principally  but  not  exclusively,  at  the  inferior 
and  posterior  portions  of  the  lungs.  This  results  mainly  from 
the  nature  of  the  diseases  which  produce  it ;  though  the  recum- 
bent, and  the  upright  or  partially  upright  position  which  the  pa- 
tient generally  preserves,  favors  the  passage  of  the  liquid  contents 
of  the  tubes  towards  those  portions.  Ely  far  the  most  frequent 
causes  of  this  rale  are  pneumonitis  and  bronchitis.  It  is  heard  in 
pulmonary  oedema,  and  in  hasmoptysis ;  but  serum  and  blood, 
being  thin  liquids,  give  a  peculiar  sharpness  to  the  sounds  produc- 
ed with  them.  The  crackling  rale  of  the  third  stage  of  phthisis, 
which  is  heard  mainly  at  the  superior  portion  of  the  lungs,  has 
generally  been  ranked  ag  a  form  of  the  sub-crepitant.  It  is,  how- 
ever, a  dry  sound,  and  is,  withal,  coarser  than  what  ordinarily 
takes  this  name.  For  these  reasons,  I  have  given  it  a  separate 
designation. 

The  mucous  rale  is  a  louder  and  more  irregular  sound  than  the 
sub-crepitant.  Indeed,  the  former  is  so  fugitive,  that  it  may  pass 
away  for  the  time,  and  not  be  restored,  until  a  cough  has  trans- 
pired. The  bubbling,  also,  of  the  former  is  more  distinctly  hur- 
ried than  that  of  the  latter.  It  is  made  only  in  some  of  the 
longer  bronchi,  where  they  are  pretty  well  filled  with  a  liquid. 
This  liquid  is  generally  pus,  or  mucus,  or  a  mixture  of  both.  Of 
course,  it  is  generally  thick,  but  not  very  tenacious.  Serum  and 
blood,  however,  will  give  rise  to  the  sound ;  but,  when  made  by 
means  of  them,  it  will  not  have  its  usual  softness  of  tone.  When 
once  heard  in  its  marked  form,  it  will  ever  afterwards  be  recog- 
nised. It  very  generally  exists  both  in  inspiration  and  in  expira- 
tion. It  is,  however,  comparatively  a  faint  sound  in  the  latter  ; 
and,  when  the  air  returns  from  the  lungs  with  but  a  feeble  force, 
the  liquid  is  not  sufficiently  agitated  to  excite  it.  The  sound 


AUSCULTATION.  123 

may  be  looked  for,  whenever  the  expectoration  indicates  that  the 
larger  bronchi  are  incumbered  with  a  liquid  which  is  not  very  te- 
nacious. It  is  produced  in  the  developed  stage  of  acute  bron- 
chitis, and  in  the  third  stage  of  both  pneumonitis  and  phthisis. 
Like  the  sub-crepitant  rale,  it  may,  also,  be  created  by  pulmonary 
cedema  and  haemoptysis.  In  some  of  these  diseases, — in  phthisis 
especially, — the  rale  is,  in  many  instances,  frequent  and  so  loud 
as  even  to  be  audible,  at  a  short  distance  from  the  thorax  of  the 
patient. 

One  other  rale  remains  to  be  considered.  It  is  the  gurgling. 
The  sound  of  this  does  not  differ  very  essentially  from  that  of 
the  mucous.  It  is,  however,  even  louder,  and  is  more  hollow ; 
but  it  is,  at  the  same  time,  more  concentrated.  It  is  produced  in 
a  cavity  partially  filled  with  a  liquid  of  moderate  tenacity,  though 
of  a  size  varying  from  that  of  a  large  pea  to  that  of  an  orange, 
or  even  to  the  dimensions  of  the  pleural  cavity,  in  which  this 
contained  liquid  is  generally  pus,  or  muco-purulent  matter.  The 
sound  occurs  in  expiration,  as  well  as  in  inspiration.  The  reason 
of  this  is,  the  returning  current  of  air,  as  well  as  the  entering, 
passes  through  the  cavity  and  is  reflected  from  its  walls  in  such  a 
manner  as  to  disturb  the  liquid.  Of  course,  the  gurgling  rale  is 
almost  continuous  in  its  existence.  It  may  cease,  however,  for  a 
time,  in  consequence  of  the  cavity's  being  emptied  of  its  con- 
tents. In  that  case,  the  sound  will  be  replaced  by  the  cavernous 
or  the  amphoric  respiration.  This  rale  is,  by  no  means,  propor- 
tioned, in  loudness,  to  the  extent  of  the  cavity.  The  quantity  of 
liquid,  the  consistency  of  the  surrounding  pulmonary  tissue,  the 
amount  of  air  admitted  to  pervade  the  cavity,  and  the  position  of 
its  point  of  ingress  in  relation  to  the  surface  of  the  liquid,  are  all 
circumstances  modifying  the  degree  of  sound.  The  diseases 
which  give  rise  to  this  rale,  are  those  in  which  pulmonary  cavi- 
ties are  formed  and  partially  filled  with  liquid  ;  and,  probably, 
forty-nine  out  of  fifty  of  these  will  be  found,  on  examination,  to 
be  tuberculous.  Pneumonic  and  gangrenous  cavities,  however, 
occasionally  yield  the  sound  ;  and  so  does  the  dilatation  of  one  of 
the  large  bronchi.  In  this  last  oase,  a  sort  of  cavity  is  formed, 
through  which  the  air  freely  passes,  both  in  inspiration  and  in  ex- 
piration. This  cavity,  if  pus  is  not  present,  may  yet  contain 


124  THORACIC    DISEASES. 

mucus  of  such  consistency  as   to  give  substantially  the  ordinary 
gurgling  sound. 

SECTION  V. 
ADVENTITIOUS    SOUNDS. 

There  are  certain  sounds,  which  have  sometimes  been  classed 
with  the  rales  or  rhonchi,  but  which,  from  the  circumstances  of 
their  formation,  do  not  fall  within  the  range  of  the  definition 
usually  given  to  that  important  class  of  sounds.  I  prefer,  there- 
fore, to  group  them  together,  as  a  heterogeneous  class,  superadded 
to  the  rales  properly  so  called.  Hence  the  propriety  of  the  des-  , 
ignation,  adventitious  sounds. 

The  first  of  these  I  term  the  emphysematous  crackling.  It  is 
pathognomonic  of  the  disease  emphysema.  In  this  disease,  the 
dilated  and  stiffened  parietes  of  the  vesicles,  rubbing  against  them- 
selves and  perhaps  against  the  pleura,  in  the  motion  produced  by 
inspiration,  cause  a  rubbing  or  crackling  soi^nd.  Dr.  Gerhard 
calls  this,  in  one  place,  the  rustling  sound  of  inspiration,  and  in 
another,  the  dry,  sub-crepitant  rhonchus.  In  strictness  of  defi- 
nition, however,  it  seems  to  me  to  belong  to  the  adventitious 
sounds;  for,  though  it  results  from  the  respiration,  it  is  made  me- 
diately, and  not  immediately,  by  the  action  of  the  air.  The  air 
distends  the  lungs,  and  the  sound  is  the  consequent  rustling  of 
the  hardened  and  not  very  pliant  membranes. 

Another  of  the  adventitious  sounds  is  the  grating  sound, — 
sometimes  called  the  creaking,  the  friction,  the  rubbing,  and  the 
new-leather  sound.  It  is  produced  by  the  friction  of  the  two 
surfaces  of  the  pleura,  when  these  surfaces  are  rough  with  the 
deposit  of  fibrin,  constituting  the  condition  which  has,  heretofore, 
been  called  that  of  false  membrane.  The  real  pathology  of  this 
condition  will  be  elsewhere  explained.  Suffice  it  here  to  say, 
that,  under  the  laws  which  govern  the  reparative  process,  the 
hyaline  fluid  or  blastema  deposited  after  the  existence  of  inflam- 
mation of  the  pleura,  renders  that  membrane  uneven.  When, 
therefore,  an  effusion  of  serous  fluid  does  not  keep  the  pulmonary 
and  the  costal  portions  of  the  pleura  separate  from  each  other, 
they  rub  together,  in  every  act  of  respiration,  and  produce  a  sound 


AUSCULTATION. 


125 


very  much  like  the  crackling  of  pieces  of  parchment  or  new 
leather.     This  sound  exists  in   both  inspiration  and  expiration. 
When  well  developed,  it  is  accompanied   with  a  thrilling  motion 
or  quivering  of  the  chest,  which  is  very  appreciable  by  the  touch. 
When  the  deposit  of  fibrin  is  small,  or  when  effused  serum  pre- 
vents the  full  contact  of  the  roughened  surfaces,  the  sound  is  im- 
perfect, and  may  very  much  resemble  the   crackling  rale,  or  the 
sub-crepitant.     They  may  generally,  however,  be  distinguished 
without   difficulty.     The   latter  rales  follow,  more  immediately 
and  regularly,  the   act  of  inspiration,  and  they  are   less  fugitive. 
The  sub-crepitant,  especially,  is,  likewise,  more  equal  in  its  crepi- 
tation.    Besides,  the  grating   sound   is  mostly  heard   towards  the 
lower  part  of  the  thorax,  where  the   movement  of  the  ribs  is  the 
greatest,  and  where  the  hyaline  deposit  is  generally  the  most  con- 
siderable.    Other  circumstances,  too,  will   ordinarily  assist  in  dis- 
criminating between    the    grating,    and  the    resembling   sounds. 
One  of  the  latter  may  be  simultaneously  heard,  in  another  part  of 
the  lung,  and  the  history  of  the  case  may  remove  all  doubts. 

The  only  other  adventitious  sound  to  be  considered  is  the  me- 
tallic tinkling.     The  name  has  its  origin  from  the  resemblance  of 
the  sound  to  the  tinkle  of  a  metallic  vessel,  when  gently  struck 
with   some   small   but   solid   substance.     A  few  years  since,  this 
sound  was  believed  to  arise  from  a  drop  of  liquid  falling  from  the 
top  of  a  cavity  upon  the  surface  of  the  fluid  occupying  the  lower 
portion  of  the  cavity.     More  recently  it  has  been  suggested,  that 
the  tinkling  is   made   by  the   bursting   of  a  bubble  of  air,  rising 
from   beneath,  upon   the  surface  of  the  fluid.     Possibly,  each  of 
these  causes  may,  at  different  times,  create  the   sound,  though  I 
believe  the  latter  to  be  altogether  the  more  common  cause.     Pos- 
sibly, too,  the   bursting  of  bubbles  in  the  air  tubes,  constituting 
the  mucous   or  the   sub-crepitant  rale,  may  sometimes  be  heard 
through  a  cavity,  which  is  filled  with  air  and  the  walls  of  which 
are  elastic,  giving  to  the  sound,  as  it  reaches  the  ear,  the  character 
of  the  metallic  tinkling.     To  produce  this  sound,  the  cavity  must 
be  large.     Generally,  it  is  the  pleural  cavity,  but   sometimes  a 
large  tuberculous  one.      In  the  latter  case,  amphoric  respiration  is 
present,  and  determines  the   patient's  pathological   condition.     Of 
course,  the  tinkling  sound  is  not  of  much  practical  value. 


THORACIC    DISEASES. 

SECTION   VI. 
THE    SOUNDS    OF    THE    VOICE. 

In  discriminating,  between  a  healthy  and  a  diseased  condition 
of  the  lungs,  and  between  different  forms  of  disease,  we  are 
sometimes  considerably  aided  by  the  peculiar  sound  of  the  voice, 
as  heard  from  the  thorax.  Several  circumstances,  however,  so 
modify  the  vocal  vibrations,  that  we  cannot  rely  on  this  means  of 
diagnosis  alone.  The  comparative  thickness  of  the  intercostal 
muscles  and  the  amount  of  adipose  tissue  upon  them,  have  an 
effect  on  the  sound, — a  patient  the  walls  of  whose  chest  are  ema- 
ciated yielding  a  fuller  resonance  in  consequence  ;  while  a  large 
deposit  of  fat  renders  the  sound  feeble.  The  natural  tone  of 
voice,  too,  is  concerned  with  its  power  of  vibration.  A  bass  voice 
is  more  resonant  than  a  higher-toned  one,  and  a  naturally  strong 
voice  than  a  feeble  one.  Still,  to  some  extent,  the  peculiarities 
of  the  voice  correspond  with  the  varieties  of  respiration.  "  In 
the  ordinary  act  of  speaking,  the  voice  vibrates  throughout  the 
chest;  and,  if  the  hand  be  placed  upon  its  parietes,  a  slight  tremor 
is  very  perceptible.  If  we  apply  one  ear  to  it,  the  other  being 
closed,  we  shall  hear  a  distant  and  confused  sound."  This  sound 
is  comparatively  loud,  if  we  listen  immediately  over  the  large 
bronchi ;  and  it  becomes  less,  in  proportion  to  the  increase  of  the 
distance  from  those  parts.  The  principal  variation  from  exact 
proportion,  has  reference  to  the  summit  of  the  lungs,  especially 
on  the  right  side.  The  reasons  already  named,  as  varying  the 
bronchial  sound  of  respiration,  have,  also,  an  equal  effect  on  the 
voice. 

Generally,  where  the  vesicular  structure  abounds,  and  the  bron- 
chial ramifications  are  small,  we  have,  in  health,  but  a  faint  vibra- 
tion of  the  voice.  This  may,  therefore,  be  said  to  correspond 
with  the  vesicular  murmur.  Directly  over  the  large  bronchi, 
where  the  blowing  bronchial  sound  of  health  is  most  marked, 
we  have  a  strong  vibration  of  the  voice,  which  is  usually  called 
bronchophony,  a  sound  from  the  bronchi.  This  may  be  de- 
scribed as  a  thrilling  sound,  in  which  no  articulation  is  discovera- 
ble, and  which  seems  to  reach  the  ear  as  coming  from  the  vocal 


AUSCULTATION. 


127 


cords  or  some  point  at  a  distance.  It  corresponds  with  the  blow- 
ing bronchial  respiration. 

Diseases  of  the  chest  often  modify  the  vocal  resonance.  Some- 
times it  is  diminished.  In  emphysema,  for  instance,  the  increased 
quantity  of  air  in  the  lung,  renders  it  a  bad  conductor  of  sound ; 
and,  hence  the  voice  is  heard  more  feebly.  Liquid  effusions  into 
the  pleural  cavity,  if  considerable,  compress  the  spongy  texture  of 
the  lungs,  flatten  the  bronchi,  and  partially  or  wholly  destroy  the 
vocal  resonance. 

Most  diseases  of  the  chest,  however,  cause  the  voice  to  resound 
more  strongly  than  it  does  in  health.  Bronchophony,  as  already 
defined,  is  generally  produced,  where  it  is  not  heard  in  health,  by 
those  diseases  which  cause  bronchial  respiration  ;  and  it  is  pro- 
duced in  the  same  portions  of  the  lungs  as  the  bronchial  respira- 
tion. This  sound,  too,  is  usually  more  or  less  intense,  according 
as  the  bronchial  respiration  is  more  or  less  shrill  and  tubal.  The 
principal  variation  from  the  rale  is  in  the  case  in  which  accumu- 
lated mucus  obstructs  the  bronchi  too  fully  to  be  removed  by  the 
act  of  speaking,  but  so  that  it  is  removed  by  a  strong  respiration. 
In  this  case,  the  vibrations  of  the  voice  are  prevented,  though 
the  respiratory  sound  is  not.  In  the  most  marked  form  of  bron- 
ehophony,  articulation  seems  almost  to  be  heard,  and  the  sound 
varies  but  little  from  pectoriloquy.  The  induration  of  a  portion 
of  the  lung,  in  the  second  stage  of  phthisis,  yields  bronchopho- 
ny ;  and  pneumonitis,  in  the  stage  of  hepatization,  produces  it  in 
its  most  perfect  form,  Dilatation  of  the  bronchi  will  increase  the 
vocal  resonance;  but  this  is  substantially  of  the  nature  of  pecto- 
riloquy. In  ail  these  cases,  the  principal  evidence  of  the  presence 
of  disease,  derivable  from  bronchophony,  is  its  existence  at  points 
from  which  it  is  not  heard  in  health.  It  is  often,  however,  de- 
cidedly more  distinct,  than  it  ever  is  in  health. 

Pectoriloquy,  a  speaking  from  the  chest,  is  a  resonance  of  the 
voice  yielded  by  an  ordinary  cavity  in  the  lung,  or  such  a  cavity 
as  produces  cavernous  respiration.  Of  course,  it  corresponds 
essentially  with  cavernous  respiration.  In  its  most  marked  form, 
the  vocal  sound  seems  almost  to  be  articulate,  and  to  have  its 
origin  in  the  cavity  from  which  it  comes  to  the  ear.  In  these 
two  particulars,  the  resonance  differs  from  that  of  bronchophony. 


128  THORACIC    DISEASES. 

When  somewhat  imperfect,  however,  the  former  can  hardly  be 
distinguished  from  the  latter.  A  large  bronchial  tube  surrounded 
by  hardened  pulmonary  tissue  may  yield  even  a  more  thrilling 
sound  than  a  cavity  surrounded  by  spongy  pulmonary  structure 
and  not  so  situated  as  freely  to  receive  the  external  air.  The 
most  perfect  pectoriloquy  comes  from  a  cavity  of  moderate  size, 
entirely  emptied,  and  having  indurated  walls.  But  pectoriloquy 
is  seldom  very  perfect.  A  cavity  is  liable  to  be  obstructed  with 
muco-purulent  matter,  even  if  the  other  requisites  to  the  creation 
of  the  sound  are  permanently  present.  Hence  the  sound  is  fugi- 
tive ;  and  cavernous  respiration,  together  with  the  gurgling  rale, 
is  a  more  valuable  guide  in  detecting  the  pathological  condition, 
than  pectoriloquy. 

Amphoric  resonance  of  voice  is  a  modification  of  pectoriloquy, 
heard  from  such  a  cavity  as  gives  amphoric  respiration.  The 
difference  between  this  sound,  when  marked,  and  pectoriloquy  is, 
the  former  seems  somewhat  "more  hollow,  more  distant,  and 
more  diffused,"  than  the  latter.  If  the  cavity  is  one  of  consider- 
able size,  the  resonance  is  generally  a  clear  ringing  or  quite  metal- 
lic sound,  somewhat  like  the  noise  produced  by  speaking  into  a 
glass  tumbler  or  large  open-mouthed  vial,  without  entirely  clos- 
ing the  opening.  This  is  especially  the  case,  when  the  pleural 
sac  becomes  the  cavity,  in  consequence  of  a  communication  made 
with  the  bronchi.  In  a  tuberculous,  pneumonic,  or  gangrenous 
cavity,  the  tone  is  not  so  short  and  the  resonance  is  not  so  clear. 
It  may  even  happen,  that  a  cavity  producing  the'  amphoric  respir- 
ation, but,  not  being  very  large,  shall  be  in  such  a  condition,  that 
the  amphoric  resonance  will  scarcely  differ  from  pectoriloquy.  If 
the  parenchyma  of  the  lungs  around  the  cavity  is  soft  and  per- 
meable, the  resonance  is  generally  quite  obscure.  If  the  bronchi 
become  obstructed,  it  will,  of  course,  entirely  cease. 

Egophony,  sometimes  written  aegophony  and  hsegophony,  is  a 
peculiar  quivering  sound,  and  takes  its  name  from  two  Greek 
words  signifying  the  sound  of  a  goat.  It  resembles  the  bleating 
of  a  goat  or  a  sheep,  and  may  be  tolerably  well  imitated  by 
speaking  through  a  common  speaking  trumpet.  The  sound  is 
really  bronchophony,  modified  by  the  influence  of  a  pleuritic 
effusion,  or  the  existence  of  a  thin  liquid  in  the  pleural  cavity. 


RATIONAL    SYMPTOMS*  129 

In  order  to  its  production,  however,  it  is  necessary  that  the  quan- 
tity of  the  liquid  be  limited.  Generally,  the  lung  must  be  mod- 
erately compressed,  but  not  much  flattened  by  the  pressure. 
Hence  the  sound  is  heard,  in  the  second  stage  of  pleuritis  or  in 
hydrothorax,  when  the  water  is  beginning  to  collect,  and  when  it 
is  nearly  absorbed.  Too  small  a  quantity  is  riot  sufficient  to 
afford  the  vibrations.  T^oo  much  so  compresses  the  lung  that  the 
air  is  prevented  from  sufficiently  filling  the  bronchial  tubes. 
If,  however,  the  substance  of  the  lung  happens  to  be  somewhat 
rigid  and  solid,  in  consequence  of  previous  inflammation,  so  as  to 
produce  strong  bronchial  respiration,  the  egophony  will  continue, 
as  the  water  increases,  much  longer  than  it  otherwise  would  do. 
It  may  last  even  during  the  whole  existence  of  the  disease. 
Still  it  is,  ordinarily,  quite  transitory,  passing  away  in  a  few 
days.  Egophony,  when  existing,  if  the  patient  sustains  the  up- 
right posture,  is  most  distinctly  heard,  posteriorly,  near  the  lower 
margin  of  the  scapulas  ;  but,  with  a  change  of  position,  there  is 
a  change  in  the  audibleness  of  the  sound, — -it  being  best  heard 
about  the  upper  portion  of  the  liquid,  except  so  far  as  obstacles  to 
the  conduction  of  the  sound  modify  the  result. 


CHAPTER   X. 

RATIONAL    SYMPTOMS. 

SECTION  I. 

D  Y  S  P  N  CE  A . 

As  diseases  of  the  thorax,  to  a  greater  or  less  extent,  affect  the 
respiration,  a  few  general  remarks  on  the  subject  of  dyspnoea 
are  not  inappropriate  in  this  place.  There  are  four  circum- 
stances, particularly,  the  existence  of  any  one  of  which  will 
disorder  the  respiration,  unless  its  influence  is  by  some  means 
counterbalanced.  These  circumstances  are  certain  disordered 
conditions  of  the  blood,  a  deficiency  in  the  quality  or  quantity  of 
inspired  air,  a  defect  in  the  machinery  designed  to  bring  the  blood 
and  the  air  into  contact,  and  a  diseased  state  of  the  nerves,  whose 
office  is  to  invite  to  action  the  muscles  of  respiration.  To  some 
17 


130  THORACIC    DISEASES. 

extent  there  may  be  a  balance  of  influences.  For  instance,  the 
distress  which  would  otherwise  arise  from  a  deficiency  in  the 
quality  of  air  allowed  to  enter  the  lungs,  may  be  prevented  by 
such  a  diminution  of  nervous  sensibility  as  renders  the  patient 
insensible  to  the  want  experienced.  Dr.  C.  J.  B.  Williams  has 
given  us  the  following  table,  showing  what  he  calls  "  the  proxi- 
mate causes  of  dyspnoea." 

The  table  is  very  accurate  and  appropriate  ;  though  not  being 
founded  directly  on  the  circumstances  which  I  have  named  as 
remote  causes,  the  classification  is  not  what  those  circumstances 
would  directly  suggest.  I  would  here  remark  that  the  original 
import  of  the  term,  dyspnoea,  is  difficult  breathing,  and  Dr.  Wil- 
liams has  here  used  it  in  a  sense  so  extensive  as  to  embrace  the 
slow  labored  respiration  of  coma,  though  it  is  ordinarily  limited 
to  what  is  hurried  and  distressing,  and  it  is  in  this  sense,  mainly, 
that  it  is  concerned  with  diseases  of  the  thorax. 

1.      BY   IMPEDING   THE   ACCESS    OF    PUKE   AIK    TO  THB  LCXGS. 

a.  Mechanical. 

Rigidity  of  parts  of  the  respiratory  machine: — 

e.g.  Ossification  of  cartilages ;  induration  of  the  pleura  ;  rickety  distortions/ 
Pressure  on  ditto  : — 

e.g.  Tumors  or  dropsies  of  the  abdomen. 
Obstructions  of  the  air-tubes  : — • 
e.g.  Effusions  in,  swellings  of,  tumors  pressing  on,  the  air-tubes  j 

Spasm  of  the  glottis ;  spasm  of  the  bronchi. 
Compression  of  the  lungs : — 
e.g.  Effusions  or  tumors  in  pleural  sac ; 
Pleurisy, 
Hydrothorax, 
Pheumothorax, 
Aneurism,  &c. 

Alterations  in  the  tissue  of  the  lungs : — • 
e.g.  Engorgement, 
Effusions : — 

(Edema, 
Hepatization, 
Tubercle,  &c. 
Altered  structure : — 
Emphysema, 
Dilated  bronchi, 

Vomicae,  &c. 

b.  Chemical. 

Deficiency  of  oxygen  in  the  air : — 
e.ff.  Mephitic  gaee? ;  rarified  air. 


RATIONAL    SYMPTOMS.  131 

c.    Vital. 

Pain  of  parts  moved  in  respiration  : — 

•e.g.  Pleurodynia;  pleuritis;  peritonitis,  &c. 
Paralysis  of  muscles  of  respiration  : — 

e.g.  Injuries  of  the  spinal  marrow  on  the  neck,  <fec. 

Paralysis  of  the  bronchi  (?) 
Weakness  of  ditto  : — 

e.g.  Excessive  prostration,  from  ataxic  fevers,  &c. 
Spasm  of  ditto  : — 
e.g.  Tetanus ;  spasmodic  asthma,  &c. 

2.  BY  THE  STATE  OP  THE  BLOOD. 

a.  Mechanical. 

Obstruction  to  the  passage  of  the  blood  : — 
e.g.  Diseases  of  the  heart  and  great  vessels  ;  tumors  pressing  on  them. 

b.  Chemical. 

An  excessively  venous  state  : — 

e.g.  Violent  exertion;  idiopathic  dyspnoea  (?) 
Deficiency  of  red  particles  : — 

e.g.  Aiucmia  ;  cholorosis. 

3.  BY  THE  NERVOUS  RELATIONS  OF  RESPIRATION". 

Excessive  sensibility  of  the  par  vagum  : —  , 

e.g.  Hysteric  dyspnoea  ;  cerebral  fevers  ;  neuralgia  (?) 

Defective  ditto : — 
e.g.  Coma:  narcotism,  &c.  (breathing  slow.) 

The  standard  of  healthy  respiration,  in  an  adult,  is  not  far 
from  sixteen  breaths  in  a  minute,  though  it  may  range  from 
twelve  to  twenty,  consistently  with  the  existence  of  comfortable 
health.  Disease,  especially  inflammation  of  the  lungs  and  the 
pleura,  may  increase  the  respirations  to  thirty  or  forty  per  minute, 
and  violent  disease  may  raise  them  as  high  as  even  sixty  or 
seventy.  In  children,  the  respiration,  both  in  health  and  in  dis- 
ease, is  more  rapid  in  the  increase  ratio  of  age  ;  and,  in  general, 
with  females  it  is  rather  quicker  than  with  males. 

In  acute  affections,  the  degrees  of  dyspnoea  is  usually  not  far 
from  proportionate  to  the  extent  of  the  disease.  In  chronic 
cases,  however,  it  is  quite  otherwise.  The  nervous  irritability 
may  gradually  be  so  deadened,  and  the  functions  of  the  system  so 
accommodated  to  the  depressing  influence,  that  there  shall  be 
but  little  variation  in  the  respiration,  even  though  there  is  a  great 
deal  of  thoracic  disease.  On  the  contrary,  the  nervous  irritability 
may  become  so  exalted  as  to  quicken  the  respiration  and  alarm  the 
patient  with  a  sense  of  dyspnoea,  when  the  existing  organic  dis- 
ease is  but  trifling.  Still  farther,  there  may  be  a  hurried  respiraT 


132 


THORACIC    DISEASES. 


tiori  without  the  patient's  being  sensible  enough  to  perceive  it  • 
or,  on  the  other  hand,  a  respiration  scarcely  quickened,  while  he 
anxiously  imagines  the  existence  of  serious  respiratory  disturb- 
ance. There  are  other  modifications  of  the  respiration,  caused 
particularly  by  peculiarities  of  nervous  influence;  —  such  as  the 
suspicious  breathing,  or  the  taking  now  and  then  of  a  sigh  or 
deep  breath,  —  and  comatose  breathing,  or  a  slow  and  struggling 
effort  of  vitality  to  sustain  the  respiratory  process.  The  true  nature 
of  these  conditions  I  design  to  illustrate  in  another  volume.  The 
knowledge  of  their  pathology  is  not  necessary  to  a  practical  un- 
derstanding of  the  subject  on  which  I  propose  now  to  treat. 


SECTION  II. 
COUGH. 

A  cough  is  so  common  an  attendant  of  diseases  of  the  thorax, 
that  a  few  general  remarks  on  the  subject  are  here  not  out  of 
place.  It  may  be  defined  to  be  an  abrupt  or  convulsive  expira- 
tion or  series  of  expirations,  in  which  there  is  a  continuation  of 
the  glottis,  trachea,  and  larger  bronchial  tubes.  When  several 
expirations  constitute  the  series,  this  is  immediately  succeeded  by 
a  loud  arid  forcible  inspiration,  which,  in  its  most  marked  form, 
constitutes  what  is  commonly  called  a  whoop. 

Coughs  have  many  varieties  of  character,  some  of  which  are 
expressed  by  the  phrases  a  short,  dry  or  hacking  cough,  a  nervous 
cough,  a  sonorous  cough,  a  suppressed  cough,  a  stridulous  cough, 
a  loose  cough,  a  hollow  cough,  a  spasmodic  cough.  These  terms, 
which  sufficiently  explain  themselves,  are  not  separately  charac- 
teristic of  particular  diseases  ;  as  the  same  form  may  arise  from 
different  diseases,  and  different  forms  from  the  same  disease. 
Indeed,  so  indefinite  are  the  shades  of  character  which  a  cough 
assumes,  that  its  various  phases  cannot  easily  be  described. 

Again,  coughs  may  be  classed  according  to  their  exciting 
causes.  These  are  various,  but  may  be  divided  into  two  general 
classes, — the  existence  of  some  irritating  substance  within  the 
air-tubes,  —  and  a  morbid  irritability  of  the  sentient  portions  of 
those  tubes,  or  some  portion  of  the  respiratory  apparatus.  The 


RATIONAL    SYMPTOMS.  133 

cough,  in  the  first  instance,  may  be  called  excretory  ;  and  in  the 
second,  irritative. 

The  design,  or  as  logicians  say,  the  final  cause  of  the  excre- 
tory cough,  is  to  eject  the  offending  matter  or  exciting  cause. 
Of  course  the  effect  of  agents  tending  to  suppress  it  is  injurious  ; 
and  the  object  of  remedial  means  should  be  to  assist  nature  to 
remove  that  which  creates  the  irritation,  even  though,  as  is  some- 
times the  case,  the  cough  be  thereby  increased.  The  irritative 
cough  proceeds  from  causes  which  are  governed  by  a  general  law 
in  the  animal  economy,  and  has  no  immediate  design  or  final 
cause.  Its  tendency  is  only  injurious  ;  and  the  object  of  medica- 
tion should  be  to  suppress  it,  by  subduing  the  excessive  irritability. 
But  these  classes  of  coughs,  however,  may  be,  and  often  are, 
united  ;  in  other  words,  the  cough  partakes,  in  part,  of  each 
character.  Of  course,  the  treatment  should  have  in  view  a  two- 
fold object. 

The  excretory  cough  may  be  produced  by  the  existence  of  a 
foreign  body  in  a  portion  of  the  air-tubes.  For  example,  a  per- 
son incautiously  allows  a  portion  of  food  or  drink  to  enter  the 
glottis.  This  suddenly  developes  a  cough,  the  violence  of  which 
will  be  proportioned  in  part  to  the  irritating  nature  of  the  sub- 
stance. The  effect  of  any  thing  highly  stimulating,  like  vinegar 
or  pepper,  will  be  more  severe  than  that  of  simple  water  or  bland 
food.  The  diseases  which  mostly  create  this  class  of  coughs  are 
affections  of  the  mucous  membrane  of  the  air-tubes  and  of  the 
parenchyma  of  the  lungs,  which  is  in  juxtaposition  with  this 
membrane.  In  these  diseases,  the  cough  will  be  more  or  less 
teasing  or  tickling,  according  to  the  character  of  the  excreted 
matter  in  the  tubes.  A  strong  saline  excretion  may  produce  a 
loud  sonorous  cough  ;  whereas  thick  mucous,  or  pus,  or  blood, 
with  little  chemical  power,  will  only  create  a  mild,  though,  per- 
haps, frequent  mucous  cough.  In  most  cases  of  bronchitis  and 
pneumonitis,  however,  the  cough  is  more  or  less  mixed,  and  not 
purely  of  the  excretory  kind. 

In  regard  to  the  irritative  cough,  there  may  be  an  increased 
sensibility  of  the  tubes  resulting  from  local  inflammation.  In 
bronchitis,  the  mucous  membrane  of  the  bronchi  is  inflamed,  and 
the  morbid  irritation  is  the  result.  This,  in  the  first  stage  of  the 


134  THORACIC    DISEASES. 

disease,  gives  rise  to  a  cough,  though  there  is  little  or  no  secre- 
tion. It  is  a  dry  and  perhaps  a  hard  cough  of  the  irritative  kind. 
In  the  second  and  third  stages,  the  cough  is  of  a  mixed  character. 
There  is  a  secretion  which  needs  to  be  expectorated,  and,  at  the 
same  time,  the  sensibility  of  the  tubes  is  increased  by  the  inflam- 
mation. In  pneumonitis,  the  case  is  much  the  same.  The  cough 
depends,  in  part,  on  the  irritation  of  the  mucous  membrane  of  the 
bronchi.  Incipient  tubercles,  presenting  a  moderate  but  irremova- 
ble irritation,  will  keep  up  a  hacking  cough,  with  little  or  no 
expectoration.  This  may  be  so  severe  as  to  be  quite  troublesome 
to  the  patient,  or  so  slight  as  almost  to  escape  his  notice.  In  se- 
vere ulceration  of  the  larynx,  we  have  a  stridulous  cough,  some- 
times almost  whistling,  and  sometimes  measurably  stifled.  An 
elongated  uvula  will  occasionally  so  irritate  the  fauces  as  to  pro- 
duce a  tickling  cough. 

Not  unfrequently  the  morbid  irritability  of  the  air-tubes  is 
owing  simply  to  a  weak  and  excited  state  of  the  nervous  system, 
—  no  inflammation  whatever  being  present.  In  pleuritis,  there 
is  inflammation  in  the  thorax,  but  it  does  not  directly  affect  the  air- 
tubes.  The  cough,  in  this  case,  therefore,  seems  to  be  strictly  of 
the  irritative  character.  In  consequence  of  the  pain  which  the 
cough,  in  this  disease,  is  liable  to  produce,  it  is  generally  checked, 
in  a  measure,  by  the  volition  of  the  patient.  Hence,  it  is  often 
spoken  of  as  a  suppressed  cough.  Sometimes  there  is  a  spas- 
modic contraction  of  the  air-tubes,  and  especially  of  the  aperture 
of  the  glottis,  and  the  cough  is,  accordingly,  wheezing  or  convul- 
sive. In  asthma,  the  bronchi  are  spasmodically  contracted,  and 
we  have  the  wheezing  cough.  In  pertussis,  there  is  a  spasm  of 
the  glottis,  and  we  have  a  strong  convulsive  cough,  together  with 
the  peculiar  whoop  of  that  disease,  made  by  a  full  and  forcible 
inspiration.  In  this  disease,  the  irritable  cough  is  owing  partly 
to  a  spasmodic  condition  of  the  air  passages.  There  is  also  a 
copious  secretion,  so  that  the  cough  is  excretory  as  well  as  irrita- 
tive. 

In  many  cases  of  irritative  cough,  it  would  seem  that  the 
abdominal  and  intercostal  muscles,  or,  in  general,  the  muscles  of 
respiration,  possess  a  peculiar  mobility  or  disposition  to  contrac- 
tion, and  that  to  this  fact  we  are  principally  to  look  for  the  proxi- 


RATIONAL    SYMPTOMS.  135 

mate  cause  of  the  cough.     This  is  particularly  true  of  nervous, 
and,  especially,  of  hysterical  subjects. 

Besides  the  case  of  spasmodic  contraction,  we  sometimes  have 
a  weakened  condition  of  the  circular  fibres  of  the  bronchi,  and  a 
consequent  deficient  action.  This  is  of  the  nature  of  partial 
paralysis;  and  the  cough,  from  the  unusual  openness  of  the  tubes, 
is  hollow  and  hacking.  This  cough  is  sometimes  heard  in 
chronic  bronchitis,  and,  occasionally,  in  connexion  with  febrile 
and  nervous  affections ;  and  if,  perchance,  there  exists  also  a  mor- 
bid mobility  of  the  muscles  of  respiration,  the  cough  will  be  very 
convulsive  and  paroxysmal. 

SECTION  III. 
THE    SPUTA. 

Expectoration  properly  signifies  the  act  of  expelling  something 
from  the  chest,  though  the  term  is  also  used  to  signify  the  matter 
expelled.  To  express  the  latter  sense,  however,  sputum,  the 
plural  of  which  is  sputa,  is  the  more  definite  and  desirable  term. 

Expectoration,  though  often  accomplished  in  part  by  coughing, 
is  yet,  in  a  good  measure,  a  voluntary  exercise,  consisting  of 
hawking  and  spitting.  By  the  former  act,  the  sputa  are  raised 
from  the  trachea  or  bronchial  tubes,  into  the  mouth,  and  by  the 
latter  they  are  ejected.  Children  do  not  voluntarily  expectorate 
till  they  are  about  six  years  of  age,  and  but  seldom  afterwards 
till  they  arrive  at  or  near  the  age  of  puberty.  In  advanced  age, 
persons  generally  have  less  power  of  expectoration  than  in  earlier 
life  ;  and,  in  articulo  mortis,  the  rattle  in  the  throat,  very  com- 
monly heard,  is  the  result  of  inability  to  free  the  air-passages  from 
the  accumulating  matter. 

In  order  to  hawk  effectually,  air  must  first  have  been  so 
thoroughly  inspired  as  to  pass  beyond  the  matter  to  be  expelled 
from  the  tubes.  This  matter  is  then  dislodged  by  the  forcible 
expiration  which  is  involved  in  the  act  of  hawking.  The  ana- 
tomical structure  of  the  air-passages  is  such  as  to  favor  the  ejec- 
tion of  the  sputa,  both  in  the  act  of  coughing  and  in  that  of 
hawking.  The  aggregate  of  the  calibers  of  the  smaller  bronchi 
is  considerably  greater  than  that  of  the  trunks.  The  difference 


136  THORACIC    DISEASES. 

is  in  regular  gradation  from  the  smallest  to  the  largest  tubes. 
On  mechanical  principles,  therefore,  the  air,  in  expiration,  has  to 
pass  more  rapidly  in  the  larger  than  in  the  smaller  tubes.  The 
rapidity  is  increased  as  the  aggregate  of  the  calibers.  The  rapid 
passing  of  the  outward  current  of  air  through  the  bronchial 
trunks  tends,  of  course,  to  convey  the  sputa  along  with  the  cur- 
rent, and  thus  relieve  even  the  smaller  tubes. 

The  death  of  a  dying  person  is  often  hastened  by  the  strangu- 
lating effect  of  the  sputa,  which  he  has  not  strength  enough  to 
eject  ;  and  when  the  vital  powers  are  feeble  but  not  yet  over- 
done, the  patient  may  sometimes  be  saved  from  death  by  being 
assisted  in  the  matter  of  expectoration.  This  may  be  done  by 
the  timely  administration  of  a  stimulant,  whether  capsicum, 
brandy,  carbonate  of  ammonia,  or  any  thing  else  which  is  suffi- 
ciently diffusible  and  active  in  its  effects.  It  may  sometimes  be 
done  simply  by  a  change  of  posture.  Expectoration  will  be  most 
easy  in  that  posture  in  which  the  respiration  is  the  freest ;  and 
that  generally  is  the  semi-upright.  Local  thoracic  affections, 
however,  call  for  different  positions,  according  to  their  nature  and 
circumstances.  I  have  known  a  phthisical  patient,  for  instance, 
whose  life  seemed  to  be  prolonged  for  days  and  even  weeks,  by 
his  sitting  with  his  body  nearly  perpendicular,  and  with  his  head 
supported  on  something  before  him.  In  case  of  the  existence  of 
vitality  sufficient  to  justify  the  measure,  expectoration  may  be 
aided  by  creating  emesis,  and  thereby  calling  the  respiratory  mus- 
cles into  invigorated  action,  while  at  the  same  time  the  bronchial 
tubes  are  favorably  affected.  Of  course,  this  is  a  case  for  the  ex- 
ercise of  discriminating  judgment ;  and  some  kinds  of  emetics 
will  assist  the  efforts  of  nature  much  more  than  others.  It  is  in 
this  way  only  that  young  children  can  ever  be  made  to  expecto- 
rate, except  the  violence  of  coughing  should  sometimes  force 
from  their  mouths  a  portion  of  the  sputa. 

As  to  the  matter  expectorated,  we  may  often,  from  its  appear- 
ance, judge  of  the  nature  of  an  existing  disease.  In  health  we 
expectorate  nothing  but  a  small  quantity  of  thin  glairy  substance, 
called  saliva.  Any  sputa  different  from  that  are  the  product 
of  diseased  action  ;  and,  by  their  mechanical  and  chemical 
qualities,  we  may  often  learn  something  —  sometimes  much  — 


RATIONAL    SYMPTOMS.  137 

of  the  nature  and  extent  of  the  affection.  The  quantity,  the 
color,  the  consistence,  the  form,  the  odor,  all  are  mechanical 
matters  to  be  taken  into  the  account  in  making  up  our  diagnosis 
from  the  sputa.  Occasionally,  too,  it  is  desirable  to  test  them 
chemically,  as  certain  chemical  properties  are  indicative  of  partic- 
ular diseases. 

The  character  of  the  sputa,  in  the  several  diseases  which  give 
rise  to  expectoration,  and  in  the  different  stages  of  those  diseases, 
will  be  pointed  out  as  each  pathological  condition  is  described. 
At  present  I  wish  only  to  name  and  explain  a  general  division  of 
the  matter  which  is  ordinarily  expectorated.  This  division  classes 
the  sputa  as  the  mucous,  the  albuminous,  the  watery,  and  the 
compound  kinds. 

Mucus  is  a  glutinous,  semi-transparent  or  sometimes  opaque 
matter,  not  coagulable  by  heat ;  and  mucous  sputa  are  more  or 
less  viscid,  semi-transparent  and  colorless,  or  opaque  and  yellow- 
ish. They  are  produced  by  acute  inflammation  of  the  air-tubes 
or  of  the  parenchyma  of  the  lungs.  The  glutinous  or  ropy  and 
semi-transparent  sputa  of  the  second  stage  of  bronchitis  are, 
perhaps,  as  purely  mucous  as  any  examples.  In  the  third  stage 
of  bronchitis,  the  sputa  are  opaque  and  yellowish,  —  in  the  stage 
of  hepatization  in  pneumonia  they  are  rusty  and  exceedingly 
viscid,  —  and,  in  general,  at  an  advanced  period  of  inflammation 
they  are  thick  and  are  not  exclusively  pure  mucus.  There  is,  so 
to  say,  an  adulteration  of  the  sputa,  though  they  are  essentially 
mucous. 

Coagulated  albumen  is  opaque,  and  the  albuminous  sputa  are 
always  opaque,  and,  in  general,  less  viscid  than  the  mucous- 
Of  this  kind  are  the  fibrinous  sputa  of  a  form  and  stage  of 
bronchitis,  the  simple  prevalent  sputa  of  phthisis,  and  those  com- 
pounded of  caseous  and  other  matter  united  with  the  pus.  This 
class  of  sputa  indicates  not  an  existing  acute  inflammation,  but  a 
state  of  suppuration.  This  state  may  have  immediately  succeeded 
acute  inflammation,  or  it  may  be  the  result  of  tuberculous  or 
scrofulous  disease.  Albuminous  sputa  consist  of  animal  matter 
secreted  and  passing  from  the  system. 

Watery  sputa  consist  of  a  thin  liquid,  which  is  water  rendered 
slightly  glutinous  by  the  presence  of  a  little  mucous  or  albuminous 
18 


138  THORACIC    DISEASES. 

matter.  It  often  assumes,  in  part,  the  form  of  froth.  It  appears 
to  result  from  irritation  of  the  air-tubes,  together  with  a  relaxed 
state  of  the  secreting  vessels,  or  from  such  a  congestion  of  the 
blood-vessels  and  obstruction  to  the  circulation  as  creates  a  degree 
of  effusion. 

The  compound  sputa  are  the  products  of  different  parts  in  dif- 
ferent pathological  conditions  brought  together,  or  of  one  part  in 
such  an  intermediate  pathological  state  as  to  secrete  at  once  differ- 
ent kinds  of  matter.  An  example  of  this  class  is  had  in  the 
muco-purulent  sputa  of  chronic  bronchitis  and  of  phthisis.  The 
coloring  matter  of  the  blood,  in  a  diseased  condition,  may  be 
mingled  with  other  kinds  of  sputa.  Thus  in  scorbutic  patients, 
the  sputa  may  compose  a  thin  reddish-brown  liquid,  like  prune 
juice  j  and,  in  the  last  stage  of  phthisis,  the  pulmonary  congestion 
preceding  death  may  give  a  dirty  or  brownish  tinge  to  the  puru- 
lent sputa. 

Other  points  of  consideration,  in  the  matter  of  the  sputa,  will 
naturally  find  place  in  the  delineation  of  the  various  diseases  of 
the  thorax. 


GENERAL    TREATMENT.  139 


DIVISION  III. 

GENERAL    TREATMENT, 

According  to  the  plan  of  Dr.  Newton  the  general  treatment  of 
disease  was  to  form  the  third  division  of  the  first  part  of  this 
work.  For  some  reason,  unknown  to  me,  this  was  omitted,  and 
a  description  of  particular  diseases,  forming  the  second  part  of  the 
work,  was  commenced.  In  order  to  carry  out  his  design,  I  write 
this  article,  in  which,  so  far  as  I  am  able,  I  will  embody  those 
ideas  of  treatment  which  I  learned  while  a  student  and  an  asso- 
ciate in  teaching  with  Dr.  Newton. 

With  reference  to  the  principles  of  treatment  of  which  many 
speak  —  I  mean  general  principles,  such  as  that  termed  "  similia 
similibus  curantur"  —  I  would  say,  that  to  me  they  seem  as  yet 
destitute  of  that  demonstrable  proof  which  can  be  brought  to 
corroborate  the  existence  of  the  principle  of  gravitation.  It  is  of 
no  practical  use, — because  it  leads  directly  to  conjecture,  —  to 
theorize  about  the  principle  of  life,  the  essence  of  disease,  the 
vis  medicatrix  naturce,  and  then  to  found  upon  unproved  hypo- 
theses a  system  of  treatment.  Enough  of  this  kind  of  philos- 
ophy has  already  existed  in  the  world,  — a  philosophy  which  is 
the  bane  of  science  and  the  enemy  of  improvement.  On  every 
side  we  meet  with  systems,  or  principles  of  treatment,  of  which 
the  world  of  imposture  and  dupery  contain  the  larger  share. 

Positive  science  is  founded  on  facts  ;  it  studies  only  phenomena, 
and  the  invariable  law  of  their  succession.  Whenever  we 
can  discover  the  relations  of  phenomena,  and  their  order  of  suc- 
cession, then  we  can  with  certainty  predict  results  ;  and  when  we 
can  do  this,  we  can  arrange  circumstances,  can  prescribe  medi- 
cines understandingly ;  and  know  when  remedial  agents  arrest 
the  progress  and  check  the  violence  of  disease.  Such  knowledge 
is  science,  and  its  application,  art.  Bat  owing  to  ignorance,  we 
cannot,  in  general,  attain  to  such  precision  in  the  prescription  of 
medicine. 


140  THORACIC    DISEASES. 

"  Empiricism."  says  Dr.  Hun,  "  is  art  founded  on  the  obser- 
vation of  the  relations  of  complex  phenomena  ;  scientific  art  is 
founded  on  the  observation  of  the  relations  of  phenomena  as 
analyzed  by  science."  The  empiric,  accordingly,  prescribes  for 
the  symptom  without  looking  for  its  cause,  not  seeking  to  learn  the 
organic  lesions,  whether  one  or  more;  but  the  scientific  physician 
prescribes,  so  far  as  possible,  according  to  the  nature  of  the  lesion 
from  which  the  symptoms  arise.  The  empiric  has  a  remedy 
which  has  removed  a  cough  in  several  cases  ;  therefore,  he  con- 
cludes that  it  will  always  do  so.  The  scientific  physician  knows 
that  cough  proceeds  from  various  lesions  ;  sometimes  from  ner- 
vous irritability,  in  which  case  he  would  use  an  anodyne  ; 
sometimes  from  inflammation,  in  which  case  he  would  use  relax- 
ants,  and  nauseants  and  demulcents  ;  sometimes  from  uterine 
sympathy,  in  which  case  he  would  prescribe  remedies  to  restore 
the  functions  of  that  organ. 

As  I  have  often  heard  Dr.  Newton  remark,  the  more  we  can 
analyze  phenomena,  and  the  nearer  we  can  attain  to  the  ultimate 
lesion,  or  lesions  from  which  symptoms  arise,  the  more  successful 
we  can  become  in  practice.  To  the  attainment  of  such  results, 
by  the  study  of  pathology,  the  profession  has  of  late  directed  a 
large  share  of  investigation.  And  while  attention  has  been  pro- 
fitably directed  in  that  direction,  too  little  interest  has  been  man- 
ifested in  the  discovery  and  use  of  more  efficient  and  safe  reme- 
dial agents.  And,  consequently,  among  the  majority  of  medical 
men  there  is  a  tendency,  after  learning  the  inefficiency  of  the 
usual  antiphlogistic  regimen,  to  the  adoption  of  a  negative  course 
of  treatment,  the  only  utility  of  which  is,  that  it  does  no  harm 
while  it  does  no  good.  It  is,  however,  an  established  fact  that  among 
the  more  liberal  members  of  the  profession  there  is  now  a  ten- 
dency to  the  adoption  of  the  safer  remedies.  The  use  of  the 
lancet  and  mercury  is  becoming  more  and  more  limited,  because 
common  sense  and  science  teach  that  it  is  not  necessary  to  greatly 
reduce  the  vitality  of  the  system  in  order  to  cure  disease. 
Recent  authors,  among  the  most  celebrated  of  whom  is  Dr. 
Carpenter,  now  contend  that  inflammation  is  not  an  exalted 
condition,  as  was  formerly  supposed,  but  that  it  is  a  depressed 
state  of  the  vital  force. 


GENERAL    TREATMENT.  141 

The  adoption  of  this  theory,  which,  it  seems  to  me,  is  fully 
verified  by  facts,  will  produce  a  change  in  the  practice  of  medi- 
cine ;  it  will  remove  that  false  idea  now  so  prevalent,  that 
depletion  by  the  lancet,  by  antimonials,  and  mercurials,  is  neces- 
sary in  the  removal  of  disease.  Relaxation,  effected  by  the  use 
of  water  or  its  vapor,  and  by  other  sedative  and  relaxing  agents, 
will  reduce  the  frequency  of  the  pulse  and  alleviate  inflammatory 
symptoms,  Avhile  at  the  same  time  the  relaxation  opens  the 
excretory  ducts,  and  favors  the  removal  from  the  system  of  any 
superabundance  of  serum.  This  course  of  treatment  relieves  the 
symptoms,  not  by  deadening  the  sensibilities,  so  that  the  effects 
of  the  disease  cannot  be  felt,  nor  by  taking  away  the  blood,  — 
the  red  corpuscles,  fibrin  and  serum,  the  nutrient  and  the  diluent 
parts  together,  thus  impoverishing  that  fluid, — but  it  does  it  by 
exciting  to  action  all  those  organs  whose  office  it  is  to  eliminate 
effete  or  poisonous  matter. 

The  principle,  the  truth  of  which  is  self  evident,  was  taught 
by  Dr.  Newton,  that  all  remedial  agents  should  be  of  such  a  na- 
ture as  not  to  do  injury  in  one  way,  while  they  do  good  in 
another.  Cacteris  paribus,  those  remedies  are,  therefore,  best, 
which,  while  they  tend  to  stimulate  the  diseased  organs  to  the 
performance  of  their  natural  functions,  and  while  they  produce 
that  state  of  the  system  most  favorable  to  the  free  operation  of 
the  healing  process,  do  not  injure,  by  corrosion  or  otherwise,  the 
textures  on  which  they  act.  Such  remedies  it  may  be  difficult  to 
find,  adapted  to  all  circumstances  and  to  all  cases.  For  example, 
an  emetic  of  lobelia  might  be  indicated  by  the  inflammatory 
symptoms,  but  be  contraindicated  by  the  existence  of  a  hernia. 
But  even  here  a  medium  course  can  be  pursued  ;  the  production  of 
catharsis  and  diuresis,  or  slight  nausea  in  order  to  favor  diaphoresis, 
will  be  admissible. 

The  treatment  of  disease  may  be  divided  into  prophylactic, 
curative,  and  palliative.  When  it  prevents  the  disease  from 
occurring,  it  is  then  prophylactic;  when  it  removes  the  ex- 
isting disease,  it  is  curative  ;  and  when,  on  account  of  the 
impossibility  of  its  removal,  we  merely  relieve  the  distressing 
symptoms,  it  is  palliative.  Medicine,  in  the  treatment  of  disease, 
may  be  both  curative  and  palliative.  The  remedies  of  this  two-* 


142  THORACIC    DISEASES. 

fold  nature  are  often  applicable  at  the  same  time.  While  we  use 
remedies  to  remove  the  disease,  nervines  and  anodynes  are  some- 
times efficacious  in  checking  the  violence  of  symptoms. 

When  we  prescribe  remedies  according  to  general  principles, 
and  the  treatment  adopted  is  purely  philosophical,  it  may  with 
propriety  be  called  rational  treatment. 

When  we  prescribe  without  knowing  the  why  and  the  wherefore, 
without  fully  understanding  the  nature  of  the  lesions  from  which 
symptoms  proceed,  and  the  qualities  of  the  necessary  remedies, 
then  we  act  empirically,  and  the  treatment  may  properly  be  called 
empirical  treatment.  [C.] 


BRONCHITIS,  143 


PART    II. 

PAETICULAR   DISEASES. 

DIVISION   I. 

DISEASES  CONNECTED  WITH  THE  PLEURAL  CAVITIES, 

CHAPTER  I. 

BRONCHITIS. 

This  disease  consists  in  inflammation  of  the  mucous  or  lining 
membrane  of  the  bronchial  tubes.  The  name  is  derived  from 
the  Latin,  and  also  from  our  English  word,  bronchus^  which  is 
originally  from  the  Greek,  /Spo^o^.  It  is  formed  by  dropping  us 
and  affixing  itis.  The  term  is  sometimes  employed  to  express 
inflammation  of  the  trachea,  the  glottis,  and  the  fauces,  but  such 
a  use  is  extremely  improper. 

Bronchitis  in  its  simple  and  marked  form  is  a  primary  and 
acute  disease. 

SECTION  I. 
PRIMARY    ACUTE   BRONCHITIS. 

PATHOLOGY. — Primary  acute  bronchitis  is  comparatively  a  mild 
disease,  and  not  often,  if  ever,  fatal.  Of  course,  no  opportunity 
is  afforded  directly  to  examine  the  anatomical  lesions.  It  is 
judged  of  only  by  its  analogy  to  cases  in  which  the  disease  is 
secondary — to  some  graver  and  fatal  disease.  In  those  cases  a 
post  mortem  examination  often  reveals  every  stage  of  acute 
bronchitis. 

In  them  it  is  found  that  the  mucous  membrane  is  reddened 
and  thickened.  Its  vessels  are  injected,  and  the  part  is  indurated. 
Indeed,  there  is  inflammation  of  essentially  the  same  character  as 
inflammation  in  any  other  tissue.  The  morbidly  relaxed  vessels 


144  THORACIC    DISEASES. 

becoming  over-distended,  the  blood  is  effused  immediately  around 
them ;  and,  becoming  stagnated  and  dead,  discolors  the  part, 
sometimes  producing  ecchymosis.  The  inflammation,  in  this 
case,  is  more  strictly  limited  to  the  tissue,  than  are  inflammations 
of  serous  tissues.  In  the  latter  ones,  the  subjacent  tissue  is  di- 
rectly and  principally  involved,  as  the  net-work  of  blood-vessels 
is  spread  out  immediately  beneath,  rather  than  in  the  tissue.  In 
mucous  tissues  the  larger  vessels  lie,  indeed,  beneath  the  basal 
layer,  but  the  smaller  ones  are  traceable  in  the  tissue  above  the 
basal  portion. 

In  patients  suffering  under  anemia,  inflammation  of  a  mucous 
membrane  gives  it  a  pale  rather  than  a  distinctly  red  color.  It 
loses  the  transparency  of  health,  and  becomes  decidedly  opaque. 
This  variation  from  the  ordinary  appearance  of  inflammation  is 
owing  to  the  deficiency  of  red  globules  in  the  blood. 

Stages  of  the  disease.  The  stages  of  primary  acute  bron- 
chitis are  not  very  distinctly  marked  by  anatomical  characters  or 
pathological  changes.  Indeed,  writers  have  commonly  made  but 
two  stages.  I  propose  to  make  three. 

I  call  the  first  the  incipient  stage.  In  it  the  inflammation  pro- 
duces a  slight  thickening  of  the  mucous  membrane.  The  second 
is  the  progressive  stage.  In  this4  the  membrane  is  more  thickened. 
The  third  is  the  developed  stage.  In  this  the  inflammation  is 
subsiding,  and  the  membrane  is  less  thickened. 

In  this  description  I  have  just  presented  the  pathological 
changes  in  the  different  stages  of  acute  bronchitis.  I  would  here 
add,  that  when  bronchitis  becomes  somewhat  chronic,  suppuration 
and  even  ulceration  may  supervene.  When  complicated,  too, 
with  rubeola,  or  any  like  disease,  the  larger  bronchial  tubes  may 
suppurate  and  ulcerate,  even  before  the  disease  has  been  of  very 
long  standing.  The  reason  is,  such  diseases  so  deprave  and  re- 
duce the  blood,  that  the  vital  action  becomes  deficient  at  an 
earlier  period  ;  but  this  classes  the  disease  as  chronic  bronchitis. 

Primary  acute  bronchitis  may  soon  pass  away,  leaving  the 
patient  in  his  usual  health ;  or  it  may  pass  into  chronic  bron- 
chitis; or  it  may  give  origin  to  pneumonitis,  and  gradually  sub- 
side as  the  pneumonitis  increases ;  or  by  reducing  vitality  may 
even  prepare  the  system  for  the  development  of  phthisis. 


BRONCHITIS.  145 

DIAGNOSIS.—- General  symptoms.  The  degree  of  fever  and 
prostration  of  the  system,  and  the  state  of  the  digestive  functions 
vary,  a  good  deal,  in  different  cases  of  this  disease.  Some- 
times the  general  disturbance  of  the  system  is  very  considerable, 
and  sometimes  it  is  very  slight.  Ordinarily,  the  patient  has  sensa- 
tions of  chilliness,  especially  at  the  earlier  period  of  the  attack. 
These  are  not  constant,  but  pass  away  and  return,  perhaps  fre- 
quently. Generally,  there  is  considerable  uneasiness  in  the  sys- 
tem, and  restlessness.  The  pulse  is  somewhat  accelerated.  It 
may  be  as  high  as  100  beats  or  more  per  minute,  or  it  may 
be  but  little  above  the  standard  of  health.  In  a  majority  of 
Cases,  it  is  not  more  than  80  or  90.  It  is  comparatively  soft,  and 
is  usually  not  very  hard.  It  does,  not,  indeed,  indicate  great  debil- 
ity, on  the  one  hand,  but,  on  the  other,  it  does  not  possess  great 
power.  The  respiration  is  generally  somewhat  hurried  and  shal- 
low, though  the  departure  from  the  normal  standard  is  seldom 
very  great.  Usually  the  skin  is  rather  hot  and  dry,  though  some- 
times persons  sweat  freely.  The  tongue  is  apt  to  be  somewhat 
dry ;  and  it  commpnly  has  a  thin  whitish  fur.  Occasionally,  it 
has  a  mucous  coat  of  considerable  thickness.  Usually,  this  dis- 
ease is  not  attended  by  pain  in  the  thorax ;  but  sometimes  consid- 
erable soreness  and  slight  pain,  are  felt,  particularly  at  the  time  of 
coughing,  in  the  region  of  the  longer  bronchial  tubes.  Probably, 
in  these  cases,  the  muscular  tissue  and  perhaps  some  others, 
become  involved  in  the  inflammation,  as  the  inflammation  of 
mucous  tissues  alone,  usually  at  least,  does  not  give  pain.  Very 
commonly,  the  appetite  is,  in  a  good  measure,  removed ;  though 
sometimes  it  is  but  little  disturbed.  When  the  stomach  is  consid- 
erably affected,  there  is  frequently,  also,  considerable  headache. 
This  may  result  through  the  nervous  system,  or  by  means  of  con- 
gestion of  the  cranial  blood-vessels.  Such  are  the  more  promin- 
ent general  symptoms. 

The  special  symptoms  vary  according  to  the  stages  and  severity 
of  the  disease. 

In  the  first  stage,  the  sound  of  respiration  is  rather  diminished, 
but  its  two  elements  generally  remain  in  normal  proportion.     If, 
however,  the  inflammation  affects  particularly  the  smallest  bron- 
chial tube-,  it  may,  also,  involve  the  vesicles,  or  prevent  the  full 
19 


146  THORACIC    DISEASES. 

ingress  and  egress  of  air,  so  as  somewhat  to  lessen  the  vesicular- 
sound.  This  diminution  of  the  respiratory  sound  or  of  one  of  its 
elements  is  confined  to  such  portions  of  one  or  both  of  the  lungs 
as  happen  to  be  affected.  It  is  generally  most  appreciable  some- 
where anteriorly;  and  in  the  progress  of  the  disease,  varies  some- 
what the  place  of  its  manifestation.  Percussion  affords  but  a  neg- 
ative evidence  of  the  affection,  as  the  resonance  of  health  remains. 
The  ordinary  mucous  secretion  is,  in  a  good  measure,  or  entirely 
suspended.  Of  course,  there  is  little  or  no  expectoration;  and 
this  is  the  principal  characteristic  of  this  stage.  The  cough  is 
dry  ;  but  it  is  hard  and  hoarse, — a  hard  barking  cough. 

In  the  second  stage,  in  very  mild  cases,  the  respiration  has  only 
a  peculiar  roughness  and  seems  even  stronger  than  the  respiration 
of  health ;  but,  in  cases  of  any  severity,  the  sonorous  rale  exists, 
and  occasionally  the  sibilant.  The  former  being  almost  exclu- 
sively made  in  the  large  bronchial  tubes,  is  heard  the  most  loudly 
directly  anteriorly  or  posteriorly  to  the  roots  of  the  lungs.  The 
latter,  if  it  exists,  is  heard  principally  in  immediate  proximity  to 
the  smaller  tubes,  in  which  it -is  principally  made.  The  sonorous 
rale,  when  heard,  is  pathognomonic  of  this  stage  of  bronchitis.  It 
can  be  created  by  no  other  condition  of  disease.  Percussion  gives 
the  normal  resonance,  with  the  exception,  that  there  is  a  slight 
degree  of  dullness,  when  the  inflammation  has  extended  to  the 
smallest  bronchial  tubes  and  the  air-cells.  The  secretion  of 
mucus,  in  this  stage,  has  returned  ;  but  it  is  thin,  stringy,  semi-- 
transparent, and  glairy,  in  appearance,  and  copious  in  quantity. 
The  expectoration,  of  course,  is  quite  abundant,  and  the  cough  is- 
loose  and  frequent. 

In  the  third  stage,  the  inflammation  is  lessening,  and  the 
mucous  secretion  and  expectoration  are  still  free.  The  sputa  are 
thick,  yellow,  and  opaque,  but  not  very  tenacious.  Their  in- 
creased consistency,  yellowness,  and  opacity  indicate  an  approach- 
ing resolution  of  the  disease.  The  mucus  in  the  larger  and 
medium-sized  bronchial  tubes  causes  the  mucous  and  sub-crepit- 
ant  rales,  in  those  two  classes  of  tubes  respectively.  Percussion 
is  still  resonant.  The  cough,  too,  remains  frequent,  but  it  is  even 
more  loose  than  in  the  second  stage.  It  is  also  characterized  by  a 
softness,  produced  by  the  lubricated  condition  of  the  tubes. 


BRONCHITIS. 


147 


In  the  mildest  forms  of  primary  acute  bronchitis,  the  character- 
istic sputa  of  the  third  stage  sometimes  scarcely  appear.  Again, 
where  those  sputa,  to  some  extent,  are  observed,  the  characteristic 
rales  take  place  but  slightly.  The  respiration  gradually  returns  to 
its  normal  state, — the  sputa  not  being  sufficient  to  produce,  to 
much  extent,  their  peculiar  effects.  Sometimes,  in  this  disease, 
when  the  inflammation  is  considerably  extensive  and  intense,  pal- 
pitation affords  evidence  of  its  existence.  The  air-passages  being 
obstructed  and  the  air  passing  with  difficulty,  a  portion  of  the 
chest  is  agitated  by  the  respiration,  and  the  vibration  is  felt  under 
the  hand. 

In  general,  this  disease  is  readily  distinguished  from  all  others. 
It  has  some  relation  to  pleuritis ;  but  the  special  and  the  general 
symptoms  are  too  different  to  be  confounded,  as  a  comparison  of 
one  class  with  the  the  other  will  show.  The  lancinating  pain  in 
pleuritis,  the  absence  of  expectoration,  the  dyspnoea,  the  degree  of 
fever,  &c.3  are  symptoms  very  different  from  any  exhibited  in 
bronchitis.  The  symptoms  of  pneumonitis  more  nearly  resemble 
those  of  bronchitis  ;  but  the  expectoration  in  these  two  diseases  is 
very  different.  The  crepitant  rale,  too,  of  the  first  stage  of  pneu- 
monitis and  the  shrill  bronchial  respiration  of  the  second  stage  do 
not  belong  to  bronchitis.  The  prostration  from  fever  is,  likewise, 
much  greater  in  the  former  disease  than  in  the  latter.  It  is  com- 
mon, however,  for  inflammation,  commencing  on  the  mucous 
membrane  of  the  bronchi,  to  pass  on  and  reach  the  parenchyma  of 
the  lungs ;  so  that  pneumonitis  often  has  its  origin  in  bronchitis, 
and  some  slight  degree  of  the  former  may  combine  with  a  severer 
degree  of  the  latter,  without  being  appreciable.  Pertussis,  which 
is  a  modification  of  bronchitis,  does,  indeed,  at  its  commencement, 
resemble  the  simple  affection  ;  but  the  whoop,  the  general  charac- 
ter of  the  cough,  &c.,  will  generally  enable  us  to  discriminate 
between  the  one  affection  and  the  other.  A  very  common  cause 
of  primary  acute  bronchitis  is  exposure  to  cold  and  Wet  combined. 
An  obstruction  to  capillary  action  on  the  surface  and  to  perspira- 
tion, is  produced,  the  circulation  is  disturbed,  the  vessels  of  the 
mucous  membrane  of  the  bronchi  become  congested,  and  inflam- 
mation is  set  up.  The  inhalation  of  noxious  vapors  and  of  par- 


148  THORAPIC    DISEASES. 

tides  of  dust,  whether  mineral  or  vegetable,  may  be  an  accessory 
or  even  the  primary  means  of  developing  the  disease. 

PROGNOSIS. — The  prognosis  of  primary  acute  bronchitis  is  gen- 
erally favorable.  Ordinarily,  what  danger  there  is  arises,  partly 
perhaps  from  an  immediate  effect  produced  on  the  nervous  sys- 
tem, but  more  from  the  fact  that  access  of  air  to  the  vesicles  is 
measurably  prevented,  and  the  blood  is  not  properly  arterialized. 
Sometimes,  bilious  and  gastric  symptoms  complicate  those  of  bron- 
chitis ;  but  they  are  seldom  of  so  grave  a  character  as  to  add  much 
to  the  danger  attending  the  disease.  In  aged  persons,  however,  the 
vital  powers  are  less  vigorous  than  at  the  middle  period  of  life.  Of 
course  more  constitutional  disturbance  is  created  with  them,  dep- 
uration and  expectoration  are  not  so  vigorously  maintained,  and 
the  system  is  necessarily  more  prostrated.  This  is  sometimes 
called  asthenic  acute  bronchitis.  The  greatest  danger,  however, 
arises  from  the  liability  of  the  disease  to  terminate  in  pneumonitis, 
— the  latter  affection  being  frequently  too  grave  for  the  debility 
of  advanced  life  to  withstand.  In  young  children,  there  is  a  sim- 
ilar liability,  but  evidently  from  some  different  cause,  though  pre- 
cisely what  that  cause  is  it  is  difficult  to  understand.  Certain  it 
is,  that  the  liability,  on  the  part  of  the  areolar  tissue  of  the  lungs, 
to  take  on  inflammation,  adds  very  much  to  the  danger  attending 
bronchitis  in  young  children. 

TREATMENT. — The  treatment  of  primary  acute  bronchitis  is  very 
simple.  The  indications  to  be  fulfilled  are  to  promote  the  ordin- 
ary secretions  generally,  and  especially  the  perspiration,  to  equal- 
ize the  circulation,  and  particularly  to  excite  free  expectoration. 

Towards  fulfilling  these  indications,  an  emetic  of  lobelia  inflata 
is  useful  in  equalizing  the  circulation  and  promoting  perspiration  ; 
especially,  if  the  stomach  sympathizes  and  the  appetite  is  des- 
troyed. If  an  emetic  is  to  be  given,  this  may  as  well  be  done  in 
the  first  instance.  ,  Soon  after  the  emetic,  or,  at  an  early  period  of 
the  treatment,  if  the  emetic  is  omitted,  a  simple  cathartic  should 
be  administered.  For  this  use,  nothing  is  better  than  the  leptan- 
dria  virginica.  It  may  be  given  in  a  decoction,  or  in  a  semi-liquid 
extract ;  or  the  solid  extract  may  be  used,  being  made  into  pills 


BRONCHITIS.  149 

with  the  addition  of  a  little  pulverized  capsicum  baccatum. 
Beach's  common  purgative  or  anti-bilious  powder  is  also  very 
good.  This  may  be  given  in  decoction  or  in  a  semi-liquid  extract. 

But  the  two  principal  things  to  be  done,  are  to  produce  perspi- 
ration and  to  excite  a  free  expectoration. — To  accomplish  the  for- 
mer, the  vapor  bath  or  the  pack  sheet  may  be  resorted  to,  if  the 
case  is  severe  enough  to  call  for  it ;  but,  in  ordinary  cases,  the 
vegetable  composition,  and  the  common  diaphoretic  and  anti-feb- 
rile powders  are  fully  sufficient.  I  prefer  in  combination,  the 
diaphoretic  and  the  antifebrile  powders,  the  formulas  of  which 
are  given  in  this  work.  Let  the  common  dose  be  given  every 
four  hours,  or  from  four  to  six  times  a  day.  [I  usually  find  it  more 
convenient,  and  more  agreeable  to  the  patient,  to  take  a  pill  of 
extract  of  lobelia,  instead  of  the  anti-febrile  powders,  once  in  four 
hours,  alternatively  with  some  diaphoretic  powder.  Or,  if  it  is 
desirable  to  give  the  medicine  in  powder,  the  extract  may  be  trit- 
urated with  loaf  sugar,  and  given  in  that  form.  The  free  use  of 
gum  acacia  and  licorice  water  will  be  found  serviceable.  Dr. 
Gabbert  uses  but  little  expectorant  medicine  in  this  disease, 
but  depends  almost  wholly  for  the  cure  upon  emetics  and  nau- 
seants.  After  the  fever  is  subdued  he  uses  quinine  freely.  C.] 

As  an  expectorant,  nothing  excels  the  compound  syrup  of  sanguin- 
aria  and  lobelia.  It  may  be  given  in  doses  of  from  half  a  dram 
to  a  dram,  every  two  hours;  or  be  alternated  with  the  dose  of 
diaphoretic  and  anti-febrile  powder,  and  be  given  every  four  hours. 
In  a  majority  of  cases,  the  compound  syrup  mentioned  above, 
given  every  two  or  three  hours,  in  doses  as  large  as  can  be  borne 
without  emesis  or  essential  nausea,  will  effect  a  cure,  in  a  short 
time. 


SECTION  II. 
SECONDARY    ACUTE    BRONCHITIS. 

Ordinarily  acute  bronchitis,  as  we  find  it,  is  a  primary  or  idio- 
pathic  affection ;  arid  this,  as  we  have  seen,  may  be  complicated 
with  some  other  disease,  arising  either  from  the  same  or  from  a 
different  cause.  Secondary  acute  bronchitis,  however,  is  an  acute 


150  THORACIC    DISEASES. 

inflammation  of  the  mucous  membrane  of  the  bronchi,  induced 
by  the  existence  of  some  other  disease,  which  has  previously  set 
in  and  which  still  continues.  This  other  disease  may  be  an  acute 
affection  as  typhoid  fever,  measles,  or  almost  any  one  of  the  exan- 
thematous  diseases ;  or  it  may  be  a  chronic  affection  as  emphy- 
sema, phthisis,  or  even  some  cardiac  affection.  Even  chronic 
bronchitis  may  assist  in  giving  a  new  development  to  the  acute 
disease,  which  thereby  becomes  secondary  to  the  chronic.  Gen- 
erally, in  this  latter  class  of  cases,  the  dyspnoea,  and  distress  are 
much  more  severe  than  in  the  primary  form  of  the  disease ;  and, 
in  some  cases,  the  vital  powers  maybe  so  much  embarrassed  as  to 
render  the  prognosis  unfavorable. 

The  treatment  of  secondary  acute  bronchitis  is  essentially  what 
is  adopted  in  the  primary  disease,  as  the  indications  of  cure  are 
essentially  the  same.  Expectorants  and  diaphoretics  are  the  lead- 
ing remedies.  Emetics,  laxatives,  and  diffusible  stimulants  may 
sometimes  be  required.  Sinapisms  and  other  stimulants,  applied 
externally,  particularly  upon  the  anterior  portion  of  the  thorax, 
sometimes  aid  considerably  in  effecting  the  cure.  Cold  wet  cloths, 
especially,  are  of  great  service. 


SECTION  III. 
CHRONIC    BRONCHITIS. 

In  strictness,  chronic  bronchitis  is  nothing  more  than  a  continu- 
ation and  modification  of  the  acute  disease  ;  or  the  former  may 
be  said  to  have  its  origin  in  the  latter. 

PATHOLOGY. — When  inflammation  is  not  soon  resolved,  gener- 
ally ulceration  supervenes.  This  is  a  breaking  down  of  tissue, 
and  a  manifestation  of  that  imperfect  character  of  the  reparative 
process,  which  is  attended  with  suppuration.  In  the  case  of  the 
mucous  membrane  of  the  bronchi,  when  this  change  takes  place 
and  continues  for  some  length  of  time,  acute  bronchitis  is  said  to 
be  converted  into  chronic.  Seldom,  if  ever,  does  the  ulceration 
extend  to  the  minute  ramifications  of  the  tubes ;  but  it  affects 
mainly  the  larger  bronchi,  in  connexion  with  the  trachea  and  the 


BRONCHITIS.  151 

parts  still  higher.  It  seems  inclined  to  seize  first,  on  the  folli-* 
cles;  but  those  most  fully  developed  and  best  fitted  to  receive 
inflammation,  are  situated  in  the  larger  passages.  From  these 
follicles,  the  ulceration  sometimes  extends,  with  an  irregular  out- 
line, and  involves  the  membrane  immediately  around. 

Such  being  the  anatomical  character  of  chronic  bronchitis,  it. 
of  course,  is  incapable  of  being  divided  into  stages. 

Ordinarily,  the  preceding  acute  disease  is,  for  a  time,  very  man- 
ifest. Sometimes,  however,  the  symptoms  of  chronic  bronchitis 
develop  themselves  gradually,  so  that  its  origin  is  not  generally 
referred  to  the  acute  disease.  In  this  case,  inflammatory  action 
has  previously  been  going  on,  slowly  and  almost  imperceptibly, 
but  yet  so  as  to  bring  about  the  same  results  as  when  it  has  been 
more  rapid.  This  clandestine  progress  of  the  disease  is  confined 
almost  exclusively  to  persons  in  advanced  life.  In  middle  age,  in 
a  form  at  all  marked,  it  is  very  rare  ;  and,  in  children,  it  is  uri^« 
known. 

DIAGNOSIS. — In  chronic  bronchitis,  the  sputa  and  the  cough  vary 
considerably  according  to  incidental  circumstances.  General! y} 
the  sputa  consist  mainly  of  thick,  whitish  or  yellowish  mucus ; 
but  this  is  often  mixed  with  purulent  matter,  the  result  of  suppur- 
ation and  ulceration.  Sometimes,  however,  the  matter  expector-* 
ated  is  thin,  glairy,  and  semi-transparent.  The  existence  of  this 
form  of  the  sputa  is  indicative  of  a  complex  anatomical  condition, 
and  not  one  of  mere  chronic  bronchitis.  The  air-cells  are  some- 
what dilated,  constituting  a  degree  of  emphysema  ;  and  this  gives 
rise  to  the  peculiarity  of  secretion.  Sometimes,  the  expectoration 
is  almost  wanting.  This  condition  is  produced  by  such  a  thick- 
ening of  the  mucous  membrane  as  prevents  its  discharging  its 
proper  office,  that  of  secretion  ;  consistently  with  this  condition 
the  air-cells  may  be  somewhat  dilated. 

The  cough  in  chronic  bronchitis  is  generally  loud  and  hard. 
In  the  second  condition  named,  it  is  generally  harder  than  in  the 
first ;  but,  in  both,  it  is  somewhat  loose.  In  the  third  condition, 
the  cough  is  dry  and  short,  but  still  it  is  comparatively  strong. 

The  constitutional  excitement  in  chronic  bronchitis  is  never 
great,  and  is  generally  very  slight.  In  the  first  variety  specified^ 


152  THORACIC    DISEASES. 

when  there  is  a  considerable  discharge  of  mucus  and  pus,  the  feb- 
rile symptoms  are  sometimes  quite  decided. 

As  physical  signs,  we  have,  in  the  first  variety,  the  mucous  and 
the  sub-crepitant  rales,  produced  by  the  muco-purulent  matter  in 
the  larger  and  the  medium-sized  bronchi.  The  respiration  is 
sometimes  quite  strong,  but  oftener  feeble.  Percussion  is  normal. 

This  form  of  bronchitis  is  distinguished  from  phthisis,  to  which 
it  has  some  resemblance  in  symptoms, — mainly  by  the  absence 
of  dullness  or  percussion  at  the  summit  of  the  lungs,  and  of  bron- 
chial respiration  at  the  same  part,  cavernous  respiration,  and  other 
signs  of  the  latter  affection.  It  is  apt,  however,  to  terminate  in 
phthisis,  by  preparing  the  way  for  the  introduction  of  the  latter 
disease. 

The  second  variety  generally  comes  on  gradually,  not  being 
preceded  by  any  marked  degree  of  the  acute  affection  ;  but,  when 
fully  developed,  it  is  manifested  by  the  existence  of  different  rales, 
in  different  parts  of  the  thorax,  at  the  same  time.  We  sometimes 
hear  the  sonorous,  the  sibilant,  the  mucous  and  the  sub-crepitant, 
simultaneously.  Laennec  called  this  music,  "  cantus  omnium 
avium,"  "  the  song  of  all  the  birds."  Generally,  the  tubes  of 
medium  size  are  more  affected  than  the  larger ;  and  hence  the 
sibilant  and  the  sub-crepitant  rather  have  the  predominance  over 
the  sonorous  and  the  mucous.  We  may  hear,  at  one  time,  a  por- 
tion of  these  rales,  and  not  the  whole.  For  instance,  before  there 
is  much  secretion,  inflammation  having  quietly  progressed  to  a 
certain  extent,  we  may  hear  the  sonorous  and  the  sibilant,  which 
sometimes  rule  ;  also,  a  sound  intermediate  between  these  two,  or 
a  compound  rale ;  and  afterwards,  we  may  have  the  humid,  that 
is,  the  mucous  and  the  sub-crepitant,  which,  also  may  in  charac- 
ter, approach  each  other.  But  the  disease  may  have  advanced 
farther  in  one  portion  of  the  tubes  than  in  another, — the  secretion 
having  taken  place  freely  in  one,  while  another  is  still  turgid  and 
dry;  and  this  condition  may  be  such  as  to  give  rise  to  the  simul- 
taneous existence  of  the  dry  and  one  of  the  humid  rales, — as  the 
sibilant  and  the  sub-crepitant,  -when  the  affection  is  upon  the  me- 
dium sized  bronchi,  or  the  sonorous  and  the  mucous,  when  the 
larger  tubes  are  the  seat  of  the  disease. 

In  this  form  of  the  disease,  there  is  commonly  some  dyspnoea. 


BRONCHITIS.  153 

if  there  is,  to  any  extent,  an  emphysematous  condition  of  the  air- 
cells,  it  will  be  somewhat  severe,  considerably  simulating  asthma. 
So,  too,  when  the  thickening  of  the  tubes  essentially  obstructs 
the  passage  of  air  through  them,  the  resemblance  to  asthma  will 
be  even  greater.  Percussion  is  normal. 

In  the  third  variety,  the  respiration  is  usually  feeble.  The  sib- 
ilant and  the  sonorous  rales  are  heard,  whenever  the  thickening  of 
the  tubes  is  sufficient  to  produce  them.  In  other  cases,  they  are 
wanting.  Percussion  is  normal  throughout  the  thorax ;  or,  not 
un frequently,  unnaturally  resonant,  on  account  of  the  existing 
emphysema.  Sometimes  one  of  the  adventitious  sounds,  the  em- 
physematous crackle,  is  heard,  in  consequence  of  the  rustling  of 
the  air-cells  against  one  another  or  against  the  pleura. 

On  the  whole,  the  varieties  in  the  symptomatology  of  chronic 
bronchitis  are  due,  partly  to  incidental  matters  and  different  stages 
of  the  disease,  and  partly  to  its  complication  with  another  affection. 

PROGNOSIS. — -  In  the  first  form  of  chronic  bronchitis,  the 
chances  for  entire  recovery,  under  proper  treatment,  are  good. 
With  improper  treatment,  it  may  prove  fatal.  In  the  other  forms, 
the  disease  may  be  expected  to  continue,  with  temporary  abate- 
ments in  the  symptoms,  while  life  lasts.  Unless,  however,  it 
becomes  complicated  with  other  serious  affections,  it  is  not  apt  to 
•bring  life  to  a  hasty  termination. 

TREATMENT. —  In  the  first  variety,  the  indications  to  be  fulfilled 
are  quite  similar  to  those  of  the  acute  disease.  In  severe  cases,  I 
have  found  great  benefit  from  the  repeated  use  of  vapor  baths 
and  emetics.  They  equalize  the  circulation,  and  induce  a  healthy 
action  on  the  surface.  This  necessarily  diminishes  the  irritation 
and  represses  the  morbid  action  of  the  lungs.  At  the  same  time, 
however,  expectorants  to  promote  a  healthy  action  of  the  secret- 
ing follicles  of  the  bronchi,  are  of  great  service ;  and  nothing 
serves  the  purpose  better  than  the  compound  sirup  of  sanguin- 
aria  and  lobelia.  Of  course,  the  alvine  discharges  and  all  the 
secretions  should  be  kept  free. 

But  notwithstanding  the  liability  to  febrile  excitement  in  this 
form  of  disease,  the  constitution  often  needs  sustaining  with 
20 


154  THORACIC    DISEASES. 

some  simple  vegetable  tonic,  as  the  common  spiced  bitters, 
quinine  or  salicine.  In  one  very  aggravated  case-,  I  used  the 
vapor  bath  and  an  emetic,  every  other  day,  for  ten  days  ;  and,  for 
intermediate  treatment,  I  gave  an  expectorant  and  tonic  in  connec- 
tion. When  I  commenced  the  treatment  of  the  patient,  he 
expectorated  from  one  to  two  pints  of  muco-purulent  matter 
daily.  At  the  expiration  of  ten  days,  the  symptoms  were  greatly 
abated  ;  and,  by  continuing  the  expectorant  and  tonic  treatment 
alone  for  two  weeks  longer,  he  was  restored  to  health,  and  has 
continued  well  to  this  day. 

Local  applications  to  the  chest  are  sometimes  serviceable.  Wet 
cloths  will  absorb  morbific  matter ;  and,  if  there  is  any  active 
inflammation,  they  will  aid  in  allaying  it.  Occasionally,  when 
the  vital  powers  are  not  very  active,  I  have  found  a  decided 
benefit  from  the  use  of  an  irritating  plaster,  anteriorly,  over  the 
superior  lobes  of  the  lungs,  or  on  the  spine,  over  some  of  the  last 
cervical  and  first  dorsal  vertebrae.  For  this  purpose,  Dr.  Hill's 
irritating  plaster  may  be  employed ;  or  one  may  be  made  by 
mingling  pulverized  podophyllum  peltatum  with  common  shoe- 
maker's wax,  Burgundy  pitch  or  almost  any  adhesive  material. 
This  treatment  is  best  suited  to  those  lingering  cases,  which  en- 
danger the  inducing  of  tuberculous  disease,  in  these  cases,  too, 
inhaled  vapor,  properly  medicated,  as  with  rosin,  ether,  or  the 
like,  is  sometimes  of  service. 

In  the  second  and  the  third  forms  of  chronic  bronchitis  but 
little  benefit  is  to  be  expected  from  medication.  Of  course,  mild 
expectorant  and  some  general  constitutional  treatment  <will  be  of 
some  service.  [In  these  cases  the  occasional  use  of  emetics  and 
the  vapor  bath,  as  Professor  Newton  has  suggested,  is  the  best 
course  of  treatment.  Professor  Gabbert,  to  these  means  adds  the 
use  of  astringents,  such  as  bayberry  and  hemlock.  In  the  inter- 
vals between  the  administration  of  the  emetics  and  baths,  the 
compound  lobelia  pills  should  occasionally  be  given,  in  order  to 
promote  capillary  action  and  favor  expectoration.  Tonics  when 
used  in  conjunction  with  these  pills  will  seldom  excite  febrile 
action.  A  nourishing  yet  unstimulating  diet  should  be  used,  and 
the  benefits  of  a  pure  dry  atmosphere,  and  of  gentle  exercise, 
should  be  sought.  C.j 


BRONCHITIS.  155 


SECTION  IV. 
BRONCHITIS    OF    CHILDREN. 

The  bronchitis  of  children  is  primary  acute  bronchitis  modified 
by  some  peculiarities  of  constitution  on  the  part  of  children.     One 
modification  is  its  decided  tendency  to  be  converted  into  lobular 
pneumonitis.     Whether  this  tendency  is  to  be  ascribed  to   the 
delicate  structure   and  comparative  weakness   of  the   air-cells  in 
children,  in  connection   with  the  strong  respiratory  action  which 
takes  place  with  them,  or  to  the  fact,  that  children  do   not,  like 
adults,  expectorate  to  relieve    the  air-passages,  so  that  the  smallest 
tubes  and  air-cells  become  specially  oppressed,  does  not  certainly 
appear.     Another  modification  is  the  early  period  at  which  a  co- 
pious secretion  takes  place,  either  preventing  the  existence,    or 
causing  the  early  disappearance  of  the  dry  rales,  so  that  they  do 
not  fall  under  observation.     On  account  of  the  amount  of  mucus 
which  loads  the  tubes,  the  mucous  and  the  sub-crepitant  rales  are 
abundant   almost    throughout    the    continuance    of   the    disease. 
Percussion  is  generally  normal,  though  sometimes  a  little  dull,  on 
account  of  the  accumulation  of  mucus  in  the  smaller  tubes  and 
an  accompanying  congestion  of  the  blood-vessels  in  the   lungs. 
Of  course,  there  is  a  loose  cough  and  some  degree  of  dyspnoaa. 
There  is   often  considerable  constitutional  disturbance,  and  not 
unfrequently  cerebral  symptoms.     The   whole  face  is  sometimes 
flushed,  and  the  color  is  a  purplish  red,  on  account  of  the  blood's 
being  imperfectly  aerated. 

The  treatment  of  this  form  of  bronchitis  consists  essentially  in 
the  use  of  emetics,  expectorants,  and  diaphoretics.  Emetics  and 
nauseating  expectorants  are  the  more  necessary,  for  the  reason, 
that  children  do  not  voluntarily  expectorate.  With  them,  it  is 
mainly  during  the  process  of  vomiting,  that  the  mucous  secretions 
are  ejected  from  the  air-tubes.  The  antifebrile  character  of  the 
treatment  will,  of  course,  be  proportioned  to  the  amount  of 
febrile  excitement ;  and,  in  general,  regard  must  be  had,  accord- 
ing to  circumstances,  to  the  preservation  of  a  healthy  operation  of 
the  various  functions. 


156 


THORACIC    DISEASES. 


[  In  treating  the  bronchitis  of  children,  great  care  should  be 
taken  to  produce  a  free  cutaneous  secretion.  On  account  of  the 
difficulty,  always  experienced  by  them  in  taking  medicine,  the 
use  of  external  means  becomes  the  more  necessary.  The  warm 
bath,  should,  therefore,  be  frequently  applied  ;  and  in  its  applica- 
tion these  cautions  should  be  observed : — To  have  the  tempera- 
ture of  the  room  above  80  °,  to  immediately  wrap  the  child  in 
warm  flannels,  without  exposing  its  body  to  the  contact  of  air, 
and  thereby  cause  a  chill,  and  to  let  it  remain  quiet  in  bed  in 
order  to  promote  perspiration.  After  a  proper  degree  of  strength  is 
obtained  to  render  reaction  certain,  the  sponging  of  the  chest  in 
salt  water  a  little  below  the  temperature  of  the  body,  will  fortify 
the  system  against  a  relapse.  C.] 


SECTION  V. 
EPIDEMIC    BRONCHITIS. 

Epidemic  bronchitis,  commonly  called  influenza,  is  primary 
acute  bronchitis,  attended  with  febrile  symptoms  of  decidedly 
greater  intensity  than  accompany  the  ordinary  form  of  the  dis- 
ease. The  physical  signs,  in  one  case,  do  not  differ  essentially 
from  those  in  the  other.  The  character  of  the  cough  and  the 
degree  of  the  dyspnoea,  in  the  two  cases,  are  essentially  the  same ; 
but  in  influenza  an  epidemic  and  irritative  influence  is  felt,  the 
nature  of  which  is  much  like  that  which  produces  common  con- 
tinned  fever.  Of  course,  while  these  are  the  special  signs  of 
acute  bronchitis,  they  are  also,  to  some  extent,  the  general  signs 
of  continued  fever. 

The  treatment  superadds  to  that  which  is  proper  for  the  simple 
disease,  a  measure  of  those  more  decidedly  antifebrile  means 
which  are  adapted  to  ordinary  cases  of  fever.  As  far,  too,  as  the 
liver,  the  stomach,  and  other  abdominal  organs  become  implicated, 
they  require  attention  in  kind  much  the  same  as  is  demanded  by 
continued  fever.  Epidemic  bronchitis,  however,  is  seldom  a  very 
grave  disease.  The  prognosis  is  almost  always  favorable. 


BRONCHITIS.  157 

SECTION  VI. 
BRONCHITIS    OF    OLD    PEOPLE. 

The  bronchitis  of  old  people  is  only  chronic  bronchitis,  in  an 
asthenic  form,  in  consequence  of  the  diminution  of  vital  influ- 
ence on  the  part  of  those  who  are  the  subjects  of  it.  It  has  re- 
ceived various  designations.  It  has  sometimes  been  called 
catarrhiis  senilis — the  catarrh  of  old  people;  but  the  term 
catarrh,  from  Ka-a,  "  down,"  and  psw,  "  I  flow,"  ought  to  be  lim- 
ited, in  its  application,  to  inflammatory  affections  of  the  nares, 
fauces,  &c.,  and  not  to  be  extended  to  those  of  the  bronchi,  from 
which  the  discharge  is  upward  to  the  throat  and  mouth.  Again, 
it  has  been  called  peripneumonia  notha  —  bastard  or  spurious 
peripniicmonia.  Peripneumonia  is  a  compound  word  from 
crspi,  about,  and  TTVSUJXWV,  a  lung.  Notha,  from  voda,  signifies 
bastard  or  spurious.  When  the  nosological  classification  of  dis- 
eases prevailed,  and  their  pathology  was  not  much  understood, 
the  term  was  understood  to  signify  a  collection  of  symptoms 
much  like  the  following : — difficulty  of  breathing,  oppression  at 
the  chest,  obscure  pains,  a  cough,  and  an  expectoration  Of 
course,  these  symptoms  might  vary  considerably  in  the  degree  of 
their  severity,  and  yet  be  understood  to  characterize  one  disease. 

The  bronchitis  of  old  people,  properly  so  called,  is.  usually 
attended  with  a  considerable  amount  of  mucous  or  muco-puru- 
lent  discharge,  and  not  unfrequently  with  passive  congestion  of 
the  pulmonary  blood  vessels.  When  the  inflammation  mainly 
attacks  the  smaller  tubes,  it  is  said  to  stimulate  pneumonitis ;  but 
the  truth  probably  is,  that,  when  there  are  symptoms  decidedly 
like  those  of  pueumonitis,  the  parenchyma  of  the  lungs  is  not 
only  congested,  but  measurably  involved  in  inflammation,  pro- 
perly so  called.  This,  of  course,  as  vitality  with  the  aged  is 
more  or  less  reduced,  depresses  the  system  and  produces  consid- 
erable constitutional  disturbance.  The  aged,  too,  are  very  sub- 
ject to  a  degree  of  emphysema ;  and  when  this  complicates 
bronchitis,  it  aggravates  the  symptoms.  To  crown  all,  the  pa- 
tient may  take  cold,  and  superadd  new  inflammation  or  acute 


158  THORACIC    DISEASES. 

bronchitis  to  the  chronic ;  and  then,  of  necessity,  the  symptoms 
will  be  severe. 

In  some  cases  there  takes  place,  in  the  bronchitis  of  old  peo- 
ple, a  kind  of  semi-fibrinous  secretion,  of  the  same  nature  as  that 
which  takes  place  in  the  trachea,  and  sometimes  in  the  bronchi, 
in  the  bronchitis  of  children.  It  is  somewhat  like  the  hyaline 
secretion  of  inflamed  serous  membranes,  but  it  is  only  imper- 
fectly, if,  indeed,  it  can  be  said  to  be  at  all,  organized.  Such  a 
secretion  blocks  up  the  tubes,  and  prevents  the  passage  of  air  to 
the  air-cells.  It,  consequently,  produces  great  dyspnoea,  or  even 
orthopiiEea,  and  much  general  prostration  of  the  system.  When 
this  secretion  exists,  it  may  be  detected  in  the  sputa. 

•The  treatment,  in  this  form  of  disease,  is  essentially  like  that 
in  chronic  bronchitis  generally  ;  but  the  asthenic  condition  of  the 
patient  requires  that  stimulating  tonics,  especially  those  of  the 
vegetable  kind,  be,  to  a  greater  or  less  extent,  combined  with  the 
emetics,  expectorants,  and  diaphoretics  employed.  The  polygala 
senega  is  a  good  remedy,  as  it  combines  expectorant  with  stimu- 
lating tonic  properties.  As  a  rapidly  diffusible  stimulant,  too,  the 
carbonate  of  ammonia  is  good,  to  sustain  the  vital  powers. 
Sinipisms.  or  other  external  stimulants,  will  sometimes  assist  in 
allaying  the  inflammation  and  arousing  a  healthy  action  ;  and 
sometimes  properly  medicated  vapors  may  be  of  service.  In 
general,  however,  the  compound  sirup  of  lobelia  and  sanguinaria 
in  connection  with  vegetable  composition,  spiced  bitters,  capsicum 
baccatum,  &c., — constitutional  conditions  being  attended  to — will 
be  all  that  is  necessary. 


SECTION   VII. 
GENERAL    REMARKS. 

Bronchitis,  cither  as  an  acute  or  as  a  chronic  disease,  is  occa- 
sionally dependent  on  some  peculiar  diathesis,  or  the  introduction 
of  some  specific  virus  into  the  system.  Thus,  a  person  of  a 
scrofulous  habit  is,  on  that  account,  the  more  liable  to  have 
chronic  inflammation  of  the  bronchial,  in  connection  with  the 
same  kind  of  inflammation  of  the  superior  portion  of  the  respira- 


BRONCHITIS.  159 

tory  tubes,  the  nasal  cavities,  &c.,  and  there  will  be,  in  this  case} 
a  copious  secretion  of  thick  glairy  mucus.  Persons  subject  to 
attacks  of  erysipelas  or  psoriasis  will  sometimes  have  acute  bron- 
chitis developed,  in  consequence  of  the  tendency  of  the  eruptive 
diseases  to  affect  the  mucous  surface  of  the  air-passages  much  in 
the  same  manner  as  they  ordinarily  do  the  cutaneous  surface. 
The  same  is  eminently  true  of  rubeola,  variola,  &c.  A  syphilitic 
taint  in  the  blood  will  sometimes  produce  chronic  bronchitis,  the 
symptoms  of  which  are  very  similar  to  those  of  phthisis.  The 
discharges  from  the  bronchi  are  muco-purulent ;  the  system  be- 
comes emaciated  ;  and  the  constitutional  disturbance  is  serious. 
Indeed,  this  affection  does  much  to  prepare  the  way  for  the  actual 
development  of  phthisis. 

In  all  the  forms  of  bronchitis,  the  object  of  nature  in  the  mu- 
cous secretion  generally  is  to  relieve  the  congested  and  inflamed 
vessels.  The  discharge  is  excretory.  This  object,  therefore, 
whatever  may  have  given  rise  to  the  disease,  may  be  aided  by 
artificial  means.  Equalizing  the  circulation  and  promoting  the 
perspiration  also  tend  to  the  same  effect.  If  this  object  is  not 
secured,  either  by  nature  or  by  art. — if  there  is  little  or  no  dis- 
charge from  the  bronchial  tubes  and  from  the  skin,  the  tendency 
is  for  the  heart  to  become  congested  and  the  vessels  of  the  lungs 
to  become  distended,  giving  origin  to  cardiac  dilatation  and 
pulmonary  emphysema. 

Sometimes,  however,  the  secretion  continues,  without  an 
abatement  of  the  inflammation.  la  this  case,  the  discharge  is  a 
morbid  one.  The  mucous  tissue  itself  seems  to  be  in  a  morbid 
condition,  so  that  its  secretory  follicles  act  abnormally  and  do  not 
relieve  the  blood  of  those  ingredients  which  keep  up  a  morbidly- 
relaxed  and  over-distended  condition  of  the  vessels.  These,  of 
course,  are  the  cases  in  which,  particularly,  tonics  and  stimulants 
are  indicated  in  connection  with  expectorants,  for  the  purpose  of 
sustaining  a  healthy  action  of  the  mucons  follicles. 


160  THORACIC    DISEASES. 

CHAPTER   II. 

PERTUSSIS. 

PATHOLOGY.  —  I  reckon  pertussis,  or  whooping  cough,  as  a 
thoracic  disease,  although  the  affection  is  not  confined  exclusively 
to  the  bronchi.  Superior  portions  of  the  air-passages  are  also 
involved.  The  disease  is  often  ranked  as  a  variety  of  bronchitis; 
and  inflammation  of  the  bronchi  does  constitute  a  portion  of  ify 
but  does  not  the  whole.  It  involves,  also,  an  affection  of  the 
nervous  system,  producing  a  spasmodic  stricture  of  the  bronchi 
and  the  trachea,  and  especially  a  spasmodic  closure  of  the  glottis. 
The  degree  of  inflammation  and  of  spasm  varies, — both  may  be 
severe,  or  both  mild ;  or  they  may  be  united  in  different  propor- 
tions, the  one  or  the  other  predominating. 

Pertussis  is  a  contagious  dis3ase,  caused  by  a  specific  virus, 
conveyed  from  one  person  to  another,  by  the  atmosphere.  As 
the  disease  is  common  in  every  community,  and  yet  is  not  ordin- 
arily repeated  with  the  same  individual,  few  persons  escape  it  in 
childhood,  and  it  is  confined  almost  exclusively  to  that  age.  It 
has,  however,  been  said  to  occur  even  in  advanced  age  with  those 
who  have  escaped  it  in  earlier  life.  As  far  as  the  disease  consists 
in  inflammation,  it  is  like  that  of  ordinary  acute  and  chronic 
bronchitis.  The  spasmodic  condition  of  the  tubes,  however, 
commences  before  the  inflammation;  and  there  is  a  secretion 
of  whitish  mucus  which  accumulates,  especially  in  the  smaller 
bronchi,  before  any  redness  or  thickening  of  the  mucous  mem- 
brane appears.  But,  after  the  disease  has  existed  for  a  season,  the 
bronchi  become  reddened  and  thickened,  and  then  they  are  filled 
first  with  a  yellow  mucus,  and  afterwards  with  a  yellow  muco-puru- 
lent  liquid.  The  accumulation  of  the  contents  of  the  tubes, 
particularly  in  the  inferior  portions  of  the  lungs,  tends  gradually 
to  enlarge,  and  often  does  enlarge,  these  tubes.  It  sometimes 
results  in  their  permanent  dilatation.  In  some  other  cases,  the 
obstruction  of  the  smaller  tubes  leads  to  the  enlargement  — 
temporary  or  permanent — of  the  air-cells.  Occasionally  it 
would  seem  that  the  inflammation  of  the  tubes  induces  diphthe- 


PERTUSSIS.  161 

ritis,  and,  not  unfrequently,  the  inflammation  extends  to  the 
parenchyma  of  the  lungs,  at  least  to  some  of  their  lobules ;  and 
then,  of  course,  it  is  complicated  with  pneumonitis, — generally  of 
the  lobular  kind.  One  other  complication  is  liable  to  occur.  The 
paroxysms  of  coughing  obstruct  the  circulation  of  blood  through 
the  lungs,  and  thereby  congest  the  brain.  The  congestion  is 
sometimes  so  great  as  to  rupture  the  blood  vessels,  producing 
apoplexy,  convulsions  and  death. 

DIAGNOSIS. — The.  febrile  symptoms  in  pertussis,  unless  it  becomes 
complicated  with  lobular  pneumonitis  or  some  other  grave  disease, 
are  not  usually  great.  There  is.  not  great  heat  of  the  skin  ;  not 
much  excitement  of  the  pulse.  At  first,  the  symptoms  are  liable 
to  be  taken  for  those  of  primary  acute  bronchitis.  At  this  time 
the  cough  is  not  very  peculiar.  There  may  be  some  feeling  of 
constriction  in  the  chest  and  of  weight  in  the  head.  Sometimes 
there  is  a  swelling  of  the  tissues  about  the  eyes  ;  they  themselves 
are  inflamed,  and  there  is  a  propensity  to  snoring  and  the  dis- 
charge of  tears.  The  sputa,  at  first  slight  and  viscid,  become, 
as  the  disease  advances,  more  copious  and  less  tenacious. 

The  peculiarity  of  the  cough,  however,  appears  the  most  im- 
portant evidence  of  the  disease.  It  is  found  in  a  series  of  rapid 
forced  expirations,  followed  by  one  long  and  loud  inspiration,  the 
shrill  character  of  which  is  produced,  not  so  much  in  the  bronchi, 
or  even  in  the  trachea,  as  in  the  larynx  or  glottis.  The  epiglottis 
recedes,  as  if  by  the  relaxation  of  a  spasm,  and  the  exhausted 
lungs  are  filled  by  a  single  inspiration.  Instantly  a  series  of  ex- 
pirations similar  to  the  former  commences,  and  this  is  followed 
by  an  inspiration  like  the  preceding.  This  process  is  usually 
repeated  several  times,  until  at  length  a  free  expectoration  of 
mucus  occurs,  and  the  paroxysm  ends.  The  patient,  exhausted 
and  perhaps  frightened  by  its  violence,  while  existing,  soon  re- 
covers his  strength  and  spirits,  and  continues  as  cheerful  as  be- 
fore, until  a  return  of  the  paroxysm. 

As  a  paroxysm  is  approaching,  generally  some  warning  of  it  is 

had   in  a  sense  of  chilliness  on    the  surface,   of  tickling    in  the 

throat,  and  of  tightness  in  the  larynx  and  air-tubes.    This  induces 

the  sufferer  to  lay  hold  on  something  for  support,  or  to  fall  on  the 

21 


162  THORACIC    DISEASES. 

ground  for  relief.  In  severe  cases,  the  sense  of  suffocation  is 
great,  the  respiration  is  much  impeded,  the  features  are  swollen 
and  livid,  the  eyes  are  strained,  and  tears  are  copiously  shed. 
The  paroxysm  is  protracted  ;  but,  as  soon  as  it  closes,  the  patient 
is  essentially  relieved,  for  that  time,  though  some  constitutional 
symptoms  may  remain.  During  the  paroxysm,  rarely  haemopty- 
sis, but  not  unfrequently  epistaxis  occurs.  In  young  children, 
sometimes,  fsecal  and  urinary  discharges  will  involuntarily  occur. 
Temporary  asphyxia  is  not  uncommon,  and,  in  some  instances, 
this  has  proved  fatal.  This  peculiarity,  it  should  be  here  remarked, 
does  not  show  itself  until  the  cough  has  existed  for  several  days, 
—often  for  a  week  or  more.  In  the  onset,  the  attack  seems  like 
one  of  primary  acute  bronchitis.  The  paroxysms  of  whooping, 
after  they  have  commenced,  are  repeated,  sometimes  at  periods  of 
fifteen  or  twenty  minutes,  and  sometimes  much  less  frequently, — 
in  many  cases  not  returning  more  than  six  or  eight  times  in  the 
course  of  a  day.  When  there  is  much  congestion  of  the  brain, 
and,  of  course,  a  liability  to  apoplexy,  the  paroxysms  of  coughing 
are  attended  with  a  flushed  countenance,  turgid  jugular  veins, 
chemosis,  and  sometimes  epistaxis.  In  such  cases,  too,  the 
patient  will  seem  inactive  and  drowsy,  the  head  will  be  specially 
hot,  and  there  may  even  be  a  starting  in  sleep,  and  a  grinding  of 
the  teeth. 

In  this  disease,  we  sometimes  have  the  cantus  omnium  avium, 
or  the  sonorous,  the  sibilant,  the  mucous,  and  the  sub-crepitant 
rales.  A  copiousness  of  secretion  early  takes  place,  giving  rise  to 
the  humid  rales ;  and  yet  portions  of  the  tubes  remain  in  such  a 
state  as  to  continue  to  produce  the  dry  rales  also,  especially  the 
sonorous.  The  manner  in  which  I  suppose  the  last  to  be  made 
I  have  previously  pointed  out.  I  will  here  add,  that,  in  this 
disease,  we  sometimes  get  a  tone  intermediate  between  these  two 
sounds,  as  they  are  heard  in  their  marked  forms  ;  and  the  mucous 
and  the  sub-crepitant  approach  each  other.  Of  course,  if  the  dis- 
ease leads  to  other  lesions,  and  becomes  complicated  with  them, 
the  distinctive  rales  and  other  indications  of  those  lesions  will 
appear.  In  general,  after  a  paroxysm  of  coughing  has  relieved 
the  bronchi  of  their  contents,  the  respiration  is  tolerably  free  and 
expansive,  till  an  accumulation  has  again  taken  place.  This  is 


PERTUSSIS.  163 

more  particularly  true  at  the  earlier  period  of  the  disease.  After 
inflammation  has  essentially  modified  the  condition  of  the  tubes, 
the  respiration  may  be  modified  and  feeble. 

Percussion,  in  pertussis,  is  usually  about  normal.  In  case  of 
some  enlargement  of  the  bronchi  or  the  vesicles,  the  resonance 
can  hardly  be  perceptibly  increased,  though,  when  there  is  indura- 
tion of  the  lungs,  to  any  extent,  percussion  may  become  some- 
what dull. 

The  recognition  of  pertussis  is  generally  easy,  by  the  existence 
of  the  whoop,  particularly,  and  by  other  peculiarities  after  the 
lapse  of  a  week  or  two  from  the  time  at  which  the  cough  com- 
mences. Usually,  this  whoop  characterizes  the  cough  for  about 
one  month ;  at  the  expiration  of  which  time  it  essentially  ceases; 
and  after  about  two  weeks  more,  the  cough  itself  is  mainly  gone. 

Ordinarily,  the  whole  continuance  of  the  disease  is  about  eight 
weeks ;  but  it  is  protracted  to  twelve  weeks  or  more.  An  attack 
of  acute  bronchitis  will  prolong  its  existence,  and  even  return  the 
whoop,  after  it  has  ceased,  for  a  week  or  two  to  be  heard. 

The  prognosis  in  the  simple  form  of  pertussis  is  favorable.  It 
is  only  when  some  of  the  complications  already  referred  to  occur, 
that  the  case  becomes  one  of  danger. 

TREATMENT. — The  indications  to  be  fulfilled,  are  to  eject  th< 
matter  secreted  and  accumulated  in  the  air-passages ;  to  allay  the 
spasmodic  excitement :  and  to  resolve  the  inflammation. 

To  accomplish  the  first  object,  remedies  will  sometimes  be 
found  necessary,  especially  when  the  accumulation  is  considerable 
and  the  constitutional  disturbance  is  serious.  Ordinarily,  howev- 
er, expectorants,  freely  taken,  will  accomplish  all  that  it  is  desira- 
ble to  do,  in  this  particular.  To  answer  the  second  object,  anti- 
spasmodics  are  required  ;  and,  for  the  third,  diaphoretics  and  relax- 
ants  are  indicated. 

To  fulfill  all  these  ends,  especially  the  two  former,  the  com- 
pound sirup  of  lobelia  and  sanguinaria  is  admirably  adapted.  In- 
deed, in  at  least  four  cases  out  of  five,  an  ordinary  dose  of  this, 
administered  at  periods  of  from  two  to  four  hours,  will  be  all  the 
treatment  that  is  essential.  If  the  febrile  symptoms  should,  in 
any  case,  be  considerable,  an  ordinary  anti-febrile  or  diaphoretic 


164  THORACIC    DISEASES. 

powder  may  be  employed.  A  dose  may  be  given  intermediate 
between  the  doses  of  the  expectorant,  or  at  the  same  time,  at 
pleasure. 

Dr.  W.  Beach  recommends  the  following  expectorant : — Sirup  of 
squills,  wine  tincture  of  ipecac,  and  sirup  of  white  poppy,  em- 
ployed in  equal  parts.  Of  this  a  dose  is  from  one  to  two  teaspoon- 
fuls,  repeated  as  required.  This,  however,  is  an  agent  far  less 
valuable  than  the  one  above  recommended.  There  is,  in  lobelia 
and  sanguinaria,  sufficient  anti-spasmodic  and  sedative  power,  for 
the  treatment  of  all  ordinary  cases.  If,  however,  a  decidedly  nar- 
cotic article  seems  at  any  time  desirable,  the  atropa  belladonna  is 
unquestionably  the  best  article  to  be  employed.  It  may  be  given 
in  the  form  of  an  extract  or  a  tincture.  The  dose  of  the  extract 
is  from  one  sixth  to  one  twelfth  of  a  grain  for  a  child  two  years 
of  age,  to  be  given  two  or  three  times  daily,  and  to  be  gradually 
increased,  till  a  grain  or  more  is  given  daily.  Of  the  tincture,  an 
equivalent  quantity  should  be  taken;  but,  being  variously  pre- 
pared, it  differs  materially  in  the  degree  of  its  strength.  The 
dose  may,  therefore,  vary  from  five  to  eight  or  ten  drops.  I  pre- 
fer the  extract;  and  I  recommend  dissolving  a  small  quantity  in 
the  compound  sirup,  and  so  administering  it,  with  that  sirup,  in 
doses  of  from  a  twelfth  to  a  twentieth  of  a  grain. 

Gentle  aperient  medicines  should  be  given,  if  necessary  to  reg- 
ulate the  bowels,  and  all  the  secretions  should  be  kept  in  a  good 
condition. 

In  the  later  period  of  the  disease,  the  energies  of  the  system 
having  become  somewhat  reduced,  it  is  sometimes  desirable  to 
combine  some  bitter  tonic  with  the  expectorant  employed.  In 
such  cases,  a  fourth  of  a  grain  of  quinine  or  half  a  grain  of  sal- 
icine  may  be  united  with  the  dose  of  the  compound  sirup,  to  be 
given  several  times  a  day.  Or  one  or  two  drams  of  the  decoction, 
or  the  infusion  of  hydrastis  canadensis,  populustremuloides,  coccu- 
lus  palmatus,  or  some  similar  bitter  tonic,  may  be  given  in  con- 
nection with  the  compound  sirup.  I  have,  however,  seldom  found 
any  tonic  necessary  or  desirable.  If  the  proper  expectorant,  anti- 
spasmodic  and  anti-inflammatory  treatment  is  sufficiently  early  and 
vigorously  pursued,  it  will  so  far  meliorate  and  shorten  the  dis- 
ease, that  the  vital  energies  will  not  often  be  much  impaired. 


ASTHMA.  165 

By  some  practitioners,  the  macrotys  raccmosa  has  been  highly 
extolled,  as  a  remedy  for  pertussis,  suited  to  all  periods  of  the  dis- 
ease. It  possesses  alterative,  expectorant,  nervine,  and  slightly 
tonic  properties ;  and  these  cannot  fail  to  render  it  serviceable. 
It  may  be  given  in  the  form  of  an  infusion,  a  decoction,  or  a  tinct- 
ure. The  saturated  tincture  is,  for  administration,  the  most  con- 
venient of  these  forms  ;  and,  of  such  a  tincture,  the  dose  is  fifteen 
or  twenty  drops,  every  four  or  six  hours,  for  a  child  of  two  years. 
The  macrotine,  however,  which  is  the  resinoid  principle  of  the 
crude  article,  is  decidedly  the  best  preparation.  Of  this,  to  a  child 
of  two  years,  one  fourth  of  a  grain  may  be  given  every  four 
hours. 

Counter  irritants  applied  over  the  lungs,  anteriorly,  have  been 
recommended ;  but  they  are  seldom  necessary,  scarcely,  if  ever 
desirable.  They  have,  also,  been  thought  serviceable,  when  ap- 
plied between  the  shoulders,  over  the  spine,  posteriorly.  Their 
effect,  in  the  latter  position,  is  to  stimulate  the  action  of  the  nerves 
connected  with  the  function  of  respiration.  This  may,  sometimes, 
be  favorable  ;  but  it  is  not  so  much  an  increase  of  respiratory  power 
as  an  allaying  of  the  spasmodic  tendency,  that  is  wanted.  Ac- 
cordingly, it  is  not  so  much  a  stimulant  as  an  anti-spasmodic, 
which  is  required.  Hence,  a  plaster  made  of  the  extract  of  bel- 
ladonna, and  applied  between  the  shoulders,  will  alleviate  the 
symptoms  far  more  than  any  mere  stimulating  application.  In- 
deed, a  plaster  of  this  kind  is  often  decidedly  beneficial. 

[Dr.  Gabbcrt  speaks  highly  of  the  following  compound  for  the 
cure  for  pertussis: — Molasses,  and  sweet  oil  equal  parts,  tincture  of 
lobelia  one  fourth  part.  To  be  administered  like  the  common  ex- 
pectorant sirup.  C.] 


CHAPTER  III. 

ASTHMA. 


PATHOLOGY.  —  Asthma,  in  Greek  ao%a,  literally  signifies  a  gasp 
for  breath,  or  a  deep,  heavy,  laborious  breathing.  The  term,  how- 
ever, by  professional  consent,  is  now  limited  to  a  disease  which 
consists  essentially  in  a  spasmodic  constriction  of  the  bronchial 


166  THORACIC    DISEASES. 

tubes,  but  is  attended  with  great  dyspnoea,  more  or  less  paroxys- 
mal, and  a  secretion  of  thick  viscid  mucus.  From  the  nature  of 
the  case  but  little  can  be  said  of  the  pathology  of  the  disease.  It 
is  strictly  a  neurosis.  The  evidences  that  the  bronchial  tubes  are 
spasmodically  constricted  are  sufficiently  strong.  In  the  first  place, 
the  apparent  absence  of  an  inflammation,  or  other  appreciable 
lesion  favors  the  belief  that  the  difficulty  must  be  nervous. 
Again,  its  paroxysmal  character  forbids  the  supposition  of  any 
marked  or  permanent  change  wrought  in  the  structures,  but 
clearly  indicates  something  of  the  nature  of  spasm.  Then,  too, 
the  patient  has  a  sense  of  constriction  in  the  chest,  very  similar  to 
that  of  cramp  in  the  limbs  or  other  portions  of  the  body;  and, 
sometimes,  the  attack  is  actually  accompanied  by  ordinary  mani- 
festations of  cramp.  Still  further,  the  patient  experiences  the  ef- 
fects of  nervous  irritability, — such  as  great  flatulence,  and  a  urin- 
ary secretion  like  that  produced  by  hysteria.  The  losdcntice  and 
the  juvantia,  too,  indicate  the  same  thing, — the  attack  being  pro- 
duced by  almost  any  cause  of  irritation,  even  by  mental  suffering, 
and  being  relieved  more  or  less,  by  all  anti-spasmodic  agents. 
And,  finally,  the  beneficial  effects  of  galvanism,  which  not  only 
strengthens  weak  nerves,  but  relieves  the  irritable,  corroborates 
the  same  view. 

That  the  mucous  membrane  of  the  bronchi  sometimes  suffers 
inflammation,  during  the  continuance  of  the  disease,  is  unques- 
tionably true  ;  but  this  is  to  be  regarded,  rather  as  a  complication 
of  bronchitis  with  asthma,  than  as  a  part  of  the  disease  itself. 
The  fact,  too,  that  there  is  a  copious  mucous  secretion,  of  itself 
only  indicates  an  excretory  office,  the  mucous  follicles  being  irri- 
tated by  the  blood,  which  is  in  an  abnormal  condition. 

Just  how  the  action  on  the  nervous  system  is  produced,  we  do 
not  yet  sufficiently  understand.  Dr.  Watson,  with  propriety,  re- 
gards it  as  a  "  spasmodic  disorder  of  the  excito-motory  system  of 
nerves  ;  "  and  he  thinks,  that  "  the  spasm  may  be  of  centric  or  of 
eccentric  origin."  That  is,  he  thinks  the  impression  may  origin- 
ate in  the  nervous  centres,  they  responding,  somehow  but  myste- 
riously, to  certain  feelings  of  the  mind,  and  conveying  their  influ- 
ence to  the  part  affected,  through  efferent  nerves;  or  the  impres- 
sion may  originate  without,  be  conveyed,  by  afferent  nerves,  to 


ASTHMA.  167 

nervous  centres,  and  thence  be  reflected,  as  in  the  other  case. 
When  the  spasm  is  of  this  latter  character,  or  of  eccentric  origin, 
the  proximate  cause  or  immediate  influence,  I  believe,  is  often,  if 
not  always,  congestion  of  the  pulmonary  blood-vessels  ;  the  blood 
in  these  vessels  being  in  an  abnormal  condition  and  exciting  an 
abnormal  nervous  action. 

As  to  the  remote  causes,  if  we  divide  them  into  predisposing 
and  exciting,  we  may  rank,  among  the  former,  a  hereditary  influ- 
ence ;  as  the  disease  often  descends  from  parents  to  children,  and 
is  common  to  various  branches  of  the  family.  Neglect,  too,  in 
any  of  the  habits  tending  to  promote  health,  though  not  sufficient 
of  itself  to  develop  the  disease,  yet  may  predispose  to  do  it. 

The  exciting  causes  are  extremely  various;  but,  the  most  of 
them — perhaps  not  all — are  such  as  directly  affect  the  nerves  of 
respiration  or  the  mucous  membrane  of  the  air-passages, — as,  for 
instance,  the  inhalation  of  certain  perfumes  or  deleterious  gases, 
the  respiration  of  air  in  a  close  room,  and  possibly  those  changes 
of  the  atmosphere  which  are  shown  by  the  thermometer,  the  ba- 
rometer, and  the  hygrometer,  and,  indeed,  almost  any  atmospher- 
ical change.  Sometimes,  a  change  from  a  country  to  a  sea  air, 
or  vice  versa :  or  from  a  higher  and  more  airy  part  of  the  same 
town  to  a  lower  and  more  confined,  or  vice  versa,  will  induce  an 
asthmatic  attack.  With  most  persons  of  an  asthmatic  tendency, 
the  dust  of  hay  produces  a  ready  effect ;  and,  in  some  parts  of 
England  more  especially  than  in  this  country,  many  asthmatics 
cannot  pass  a  field  in  which  hay  is  being  made  in  the  summer, 
without -great  suffering.  By  this  influence  a  paroxysm  will  often 
be  immediately  developed  in  those  who  were  entirely  free  from 
any  apparent  influence  of  the  disease,  before  they  approached  the 
exciting  cause.  In  some  persons,  too,  the  dust  of  the  powder  of 
ipecacuanha  will  instantly  and  severely  excite  the  affection.  The 
suppression,  however,  of  some  normal  drain  to  the  system,  as  the 
catamenia  in  the  female,  or  of  a  long-continued  abnormal  drain 
with  either  sex,  as  the  discharge  of  an  ulcer,  by  disordering  the 
circulation  and  congesting  the  blood-vessels  of  the  bronchi,  will 
develop  the  disease.  So,  too,  sometimes,  will  the  arrest  of  a  rheu- 
matic or  a  neuralgic  affection, — by  a  direct  diversion  of  nervous 
influence.  But  the  most  common  of  all  causes,  probably,  is  ex- 


168  THORACIC    DISEASES. 

posure  to  cold,  usually  called  taking  cold.  By  this  we  are  not 
necessarily  to  understand  the  development  of  any  appreciable 
bronchitis ;  but  the  checking  of  the  perspiration  and  the  conges- 
tion of  the  bronchial  blood-vessels,  while  the  system  is  predis- 
posed to  asthma,  will  excite  the  nervous  derangement. 

The  conditions,  which,  in  the  same  individual,  give  rise  to  the 
disease,  usually  remain  nearly  the  same ;  but,  in  different  individ- 
uals, very  unlike,  and  even  the  most  opposite  conditions  will  be- 
come the  exciting  cause.  The  idiosyncrasies  in  this  disease  are 
among  the  most  striking  to  which  the  human  system  is  subject ; 
and,  in  the  present  state  of  physiological  science,  are  altogether 
inexplicable.  The  opinion  has  quite  extensively  prevailed,  that 
asthma  is,  in  its  nature,  incompatible  with  phthisis.  It  is,  howev- 
er, quite  certain  that  the  former  disease  gives  place  to  the  latter ; 
so  that  a  person  who  has  been  asthmatic  for  years,  at  length  dies 
of  tubercular  consumption. 

DIAGNOSIS.  —  The  symptoms  indicating  asthma  are  various. 
Some  of  them  are  premonitory,  and,  by  those  who  are  accustomed 
to  the  affection,  are  understood  as  warnings  of  an  approaching  at- 
tack. Among  these  are  loss  of  appetite,  flatulence,  eructation, 
languor,  irritability,  drowsiness,  oppression,  and  chilliness.  Per- 
haps, he  retires  at  night  with  a  sense  of  uncomfortableness. 

It  is  very  common  for  an  attack  actually  to  commence  some- 
time after  midnight,  or  about  2  or  3  o'clock  in  the  morning,  and 
the  general  signs  are  much  like  the  following : — Often  the  person 
is  aroused  from  sleep,  by  a  feeling  of  constriction  across  his  chest, 
or  inability  properly  to  expand  it.  He  raises  himself  in  bed,  and 
sits  bowing  forward,  perhaps  with  his  elbows  resting  on  his  knees 
drawn  up  before  him.  His  breathing  is  labored,  and  attended 
with  a  wheezing  noise,  often  so  loud  as  to  be  audible  in  another 
apartment  or  at  a  distance.  He  asks  for  more  air  to  be  admitted 
into  the  room,  and  he  makes  a  strong  voluntary  effort  to  expand 
his  chest  in  inspiration  and  to  contract  it  in  expiration  ;  or,  if  able, 
he  rises  from  his  bed,  and  hastens  to  a  door  or  a  window,  which 
he  opens,  and  at  which,  however  cold  the  weather,  he  often  long 
remains.  The  labor  of  respiration  gives  warmth  to  his  body,  and 
he  often  perspires  freely.  His  extremities,  however,  are  liable  to 


ASTHMA.  169 

become  cold,  and  his  countenance  is  generally  distressed,  pale,  and 
haggard,  though  sometimes  it  is  rather  flushed  and  turgid.  Often 
the  pulse  is  small,  feeble,  and  irregular,  though  sometimes  it  is 
scarcely  disturbed.  Sometimes  the  heart  palpitates,  and  flatulen- 
cy becomes  troublesome  ;  the  urine  becomes  copious  and  pale, 
and  even  the  faeces  are  passed  with  the  impatient  hurry  of  spas- 
modic action.  The  speech  of  the  sufferer  is  interrupted  and  dif- 
ficult ;  and  there  is  a  propensity  to  cough  which  he  sometimes 
favors,  with  the  hope  of  forcing  away  the  impediment  to  his 
breathing. 

The  disease,  however,  appears  in  different  instances,  with  very 
different  degrees  of  severity.  Sometimes  its  influence  is  so  slight, 
that  the  patient,  by  having  his  head  pretty  highly  elevated,  can 
sleep  in  bed  without  great  inconvenience.  The  disturbing  effect 
may  even  be  less  than  this.  He  sleeps  in  the  ordinary  position, 
but  is  occasionally  awakened  ;  or,  if  not  awakened,  he  has  unwel- 
come dreams,  in  consequence  of  oppression  at  the  chest  and  in- 
convenience in  respiration. 

The  physical  signs  are  mostly  of  a  negative  character.  The 
sibilant  rale,  however,  is  commonly  well  developed,  both  in 
inspiration  and  in  expiration  ;  and  it  has  the  peculiarity  of  being 
a  more  protracted  sound  than  is  heard  in  any  other  disease.  Fre- 
quently, instead  of  this  rale,  or  in  combination  with  it,  we  hear 
what  may  be  called  a  wheezing  sound,  and  may  be  described  as 
a  course  and  rough  whistling,  or  a  sound  somewhat  related  to  the 
sonorous  rale.  It  is  made  in  the  larger  aud  the  medium-sized 
tubes,  by  means  of  their  continuation  and  the  modification  of 
their  form  and  size  arising  from  the  presence  of  thick  stringy 
mucus.  Asthma  may  be  complicated  with  bronchitis,  and  then 
we  may  have  some  of  the  other  rales,  and  some  of  the  diseased 
sounds  of  respiration  ;  but  the  sibilant  rale,  and  a  modification  of 
it,  in  a  prolonged  sound,  are  all  that  strictly  characterize  asthma 
itself,  except  at  the  period  when  a  paroxysm  is  leaving.  When  a 
copious  quantity  of  mucus  is  detached  and  about  to  be  expec- 
torated, its  presence  in  the  larger  bronchi  creates  the  mucous 
rale. 

A  paroxysm  of  asthma,  usually  commencing,  as  I  have  said,  in 
the    night,    very     commonly    passes    entirely     away    with    the 
22 


170  THORACIC    DISEASES. 

approach  of  morning  light,  or  early  in  the  forenoon.  It,  however, 
is  very  liable  to  return,  each  succeeding  night,  and  annoy  the 
sufferer  nightly,  for  a  considerable  time  ;  after  which  it  may  dis- 
appear for  several  weeks  or  even  months.  With  some  persons 
who  are  subject  to  severe  attacks,  it  will,  on  being  by  any  cause 
induced,  last  for  several  days,  and,  at  length,  will  either  gradually 
decline,  or  be  suddenly  relieved  by  a  free  discharge  of  glairy 
mucus,  very  commonly  in  connection  with  vomiting,  and  a 
copious  perspiration,  and  sometimes  being  attended  with  abnor- 
mal urinary  and  fa3cal  secretions.  In  some  cases,  the  discharge 
of  mucus  is  much  greater  than  in  others.  When  it  is  somewhat 
copious,  the  asthma  is  frequently  characterized  as  humid,  but,  when 
the  discharge  is  scanty,  the  disease  is  called  dry  asthma.  This 
distinction,  however,  is  not  important.  I  will  only  add  to  this 
description  of  the  manner  in  which  the  disease  manifests  itself, 
that,  while  in  its  mildest  forms  it  is  but  little  regarded,  it  some- 
times is  so  severe  as  to  alarm  both  the  patient  and  the  attendants. 
Indeed,  suffocation  seems  almost  unavoidable.  One  person  whom 
I  have  several  times  treated,  in  the  severity  of  a  paroxysm,  has 
found  respiration,  for  hours  and  even  for  two  or  more  days,  when 
unable  to  procure  the  proper  treatment,  so  exceedingly  difficult, 
that  it  seemed  to  him,  to  use  his  own  language,  "as  though  every 
breath  must  be  the  last."  His  nervous  system,  too,  would  be  so 
generally  involved,  that  he  could  scarcely  endure  the  slightest 
whisper  in  the  room,  or  the  lightest  tread  on  the  floor. 

There  are  other  diseases   which  create  a  dyspnO3a  somewhat 
resembling  that  of  asthma.     Among  these  are  emphysema,  bron- 
chitis, tubercles,  and  such  tumors  as  press  upon  the  trachea  or  the 
larger  bronchial  tubes  ;    also,  certain  diseases  of  the   heart,  an 
aneurism  of  the  aorta,  and  the  nervous  affection,  called  angina 
pectoris.     Each  of  these  diseases,  however,  has  its  peculiarities  ; 
and  no  one  of  them  has  all  the  symptoms  characterizing  asthma. 
The  paroxysmal  character,  the  wheezing,  and  the  prolongation  of 
the  sibilant  rale,  especially,  all  differ,   in  a  marked  degree,  from 
what  is  witnessed  in  any  other  disease. 

Asthma  is  common  to  both  sexes,  but  is  experienced  by  men 
more  frequently  than  by  women.  It  is  regarded  as  belonging 
more  to  the  middle  portion  of  a  person's  life  than  to  the  extremes 


ASTHMA.  171 

of  youth  and  old  age.  In  the  latter  extreme,  I  presume,  it 
seldom  begins.  As  far,  however,  as  my  own  observation  has 
gone,  those  who  have  been  subject  to  attacks  of  it  in  middle  age 
have  pretty  generally  retained  the  liability,  as  they  have  advanced 
in  life.  It  occasionally,  too,  shows  itself  in  youth  and  even  in  the 
young.  I  once  knew  it  to  appear,  in  its  marked  form,  in  a  female 
child  aged  but  four  years. 

The  prognosis  in  asthma,  is,  in  a  sense,  almost  always  favorable  ; 
that  is,  the  disease,  not  only  does  not  prove  fatal  in  itself,  but  its 
paroxysms  are  generally  removed  in  a  short  time.  It  is  far  more 
annoying  than  it  is  really  dangerous. 

TREATMENT. —  In  delineating  the  treatment  suited  to  the  relief 
of  asthma,    I  would    premise,  that    occasionally   the  disease   is 
arrested.   ,  After   afflicting   a  person    paroxysmally  for   years,    it 
makes  its  final  exit  unbidden.     In  such  a  case,  there  is,  of  course, 
a  cause,  although  it  is  unassignable. 

But  when  means,  designed  or  undesigned,  are  used,  sometimes 
those  apparently  the  most  trifling  in  their  nature  will  prove  effec- 
tive ;  at  least,  for  a  season,  as,  for  instance,  an  apparently  insignifi- 
cant impression  made  directly  on  some  portion  of  the  nervous 
system,  or  even  only  indirectly  through  the  influence  of  the 
imagination.  Sometimes  a  slight  change  of  residence  or  of 
atmospheric  influence,  will  issue  in  speedy  relief  to  the  sufferer. 

Hygienic  means  may  also  accomplish  something  in  the  way  of 
removing  or  of  warding  off  the  disease.  Hence,  the  adoption  of  a 
more  wholesome  kind  of  food,  the  use  of  demulcent  and  alkaline 
drinks,  bathing  under  proper  circumstances,  and  other  attentions 
to  the  surface,  will  serve  as  a  protection  to  the  system. 

Among  the  more  strictly  medicinal  agents  employed  to  relieve 
paroxysms  of  asthma,  we  may  reckon  opium,  hyoscyamus,  stramo; 
nium,  digitalis,  and  other  narcotics.  These,  however,  taken  by 
the  stomach,  seldom  have  much  efficacy.  Stramonium,  tobacco, 
green  tea,  and  other  narcotics  and  anti-spasmodics  have  been 
smoked  sometimes  with  decided  advantage  ;  that  is,  the  smoke 
from  these  articles  burning,  being  drawn  into  and  diffused  through 
the  bronchial  tubes,  sometimes,  by  its  local  effect,  relaxes  the 
spasm.  So,  too,  in  some  instances,  will  the  vapor  of  camphor 


172  THORACIC    DISEASES. 

inhaled,  by  the  patient's  breathing  through  a  quill  which  contains 
a  small  quantity  of  the  gum.  The  camphor  slowly  volatilizes, 
and  thereby  comes  in  direct  contact  with  the  lungs.  The  inhala- 
tion of  the  smoke  of  dried  paper,  after  having  been  saturated 
with  nitrate  of  potassa  water  in  many  cases  will  give  relief. 

Sometimes  the  nausearits  combined  with  diaphoretics,  have 
some  favorable  effect,  as  the  sirup  of  squills  in  connection  with 
senega.  Even  ipecacuanha,  the  dust  of  which  will  induce  an 
attack  with  some  persons,  has  occasionally  afforded  partial  relief. 

Sometimes  stimulants,  as  sulphuric  ether,  or  alcoholic  stimu- 
lants, especially  brandy,  and  various  vegetable  •stimulants,  by  giv- 
ing a  more  vigorous  and  healthy  action  to  the  nerves,  afford  some 
temporary  relief.  For  a  like  reason,  irritants,  applied  between 
the  shoulders  posteriorly,  so  as  to  stimulate  the  spine,  often  have  a 
favorable  effect.  Warm  water  applied  to  the  feet,  the  spine  or 
the  chest  will  sometimes  relieve,  by  removing  congestion,  and 
relaxing  the  nervous  system.  , 

But  of  all  remedies  now  known  none  is  so  efficacious  in  afford- 
ing speedy  relief,  as  a  preparation  of  lobelia  inflata.  It  is  an 
anti-spasmodic  and  a  nervine.  En  other  words,  it  subdues  the 
spasm  and  strengthens  the  nerves.  I  prefer,  however,  to  combine 
it,  in  equal  proportion,  with  another  simple  nervine  ;  and  I  use 
either  the  cypripedium  pubescens,  or  the  scutellaria  lateriflora. 
Take  of  either  of  the  latter  nervines  one  part  and  of  lobelia  one 
part,  and  make  a  wine  tincture  with  Sicily  Madeira,  or  other  pure 
wine.  The  dose  is  one  fluid  dram,  which  may  be  repeated  in 
severe  cases,  at  intervals  of  fifteen  or  thirty  minutes,  till  it  pro- 
duces vomiting.  In  milder  cases,  the  same  dose  may  be  given, 
once  in  from  two  to  four  hours.  It  then  quiets  the  spasm  with- 
out emesis.  If,  in  union  with  this,  the  patient  takes  also  spirits 
of  turpentine,  in  doses  of  from  fifteen  to  thirty  drops  once  in  four 
hours,  perhaps  the  remedy  will  relieve  a  spasm  as  quickly  and  as 
completely  as  any  agent  now  known.  Lobelia  may  also  be 
applied  over  the  chest  anteriorly,  or  over  the  spine  behind  the 
chest  with  a  good  effect.  So,  too,  may  the  spirits  of  tur- 
pentine, used  alone,  or  united  with  lobelia  tincture,  acetic  acid, 
essential  oil  of  lemons,  or  suspended  in  the  yolk  of  an  egg. 

But  among  all  the  agents  worthy  of  a  local  application,  none, 


MORBID    CHANGES    IN    THE    BRONCHI.  173 

I  believe,  is  more  effective  than  electricity  or  galvanism.  The 
best  method  of  applying  this,  ordinarily,  is  by  the  use  of  plates  of 
copper  arid  zinc,  so  united  and  adjusted  that  the  perspiration  of 
the  body  shall  sustain  the  galvanic  action  of  the  plates.  A  com- 
mon battery,  however,  may  he  employed,  the  positive  and  the 
negative  buttons  being  placed,  one  over  the  last  cervical  or  the 
first  dorsal  vertebra  posteriorly,  and  the  other  anteriorly  over  the 
sternum  and  near  the  ensiform  cartilage. 

The  means  thus  far  named  are  principally  employed  to  palliate 
or  relieve  a  paroxysm  ;  though  some  of  them  may,  with  propriety, 
be  employed  to  keep  in  subjection  the  tendency  to  attacks.  Other 
remedies  have  been  recommended,  to  be  regularly  or  occasionally 
employed  to  subdue  the  asthmatic  propensity.  Among  these 
none  has  a  greater  reputation,  or  has  been  more  effective,  probably, 
than  the  seed  of  the  sinapis  alba,  called  the  white  or  English 
mustard.  This  should  be  taken  unground,  in  doses  of  a  full  tea- 
spoonful  or  more  in  connection  with  each  meal. 

In  the  severe  case  to  which  I  have  already  referred,  the 
paroxysm  would  always  be  greatly  palliated  by  the  use  of  the 
tincture  of  lobelia  and  cypripedium.  Still,  they  would  return  ; 
and  the  propensity  to  the  attacks  seemed  scarcely  lessened  by  any 
agent  employed,  till  the  patient  resorted  to  the  use  of  the  white 
mustard,  in  doses  as  above  directed.  Since  commencing  the  use 
of  this  remedy,  now  more  than  a  year,  he  has  been  almost  entirely 
exempt  from  asthmatic  attacks. 


CHAPTER  IV. 

MORBID    CHANGES    IN    THE    BRONCHI. 

PATHOLOGY. — There  are  two  classes  of  lesions  to  which  the 
bronchi  are  subject,  and  which  uniformly  result  from  pertussis  or 
some  form  of  bronchitis.  They  are  dilatation  and  contraction. 
Though  they  are  so  different  from  each  other,  and,  in  some 
respects,  opposed,  yet  they  have  also  points  of  intimate  relation, 
and  I  chqose,  therefore,  to  consider  them  in  connection.  The 
former  is,  by  far,  the  more  frequent  lesion,  and  is  worthy  of 
more  careful  consideration.  It  is  produced  by  the  violence  of 


174  THORACIC    DISEASES. 

coughing,  and  perhaps,  in  part,  by  the  pressure  of  a  large  quan- 
tity of  mucus  within  the  tubes.  At  any  rate,  it  is  found  to  exist 
in  connection  with  a  copious  secretion,  which  is  not  readily 
expectorated. 

Dilatation  of  the  bronchi  has  several  modifications  of  form. 
Sometimes  a  single  bronchus,  or  several  ramifications  of  bronchi, 
become  rather  uniformly  enlarged  throughout ;  or  the  branches 
may  even  be  larger  than  the  principal  trunk  affected.  In  this 
case,  a  tube,  which,  while  of  a  normal  size,  would  only  admit  a 
common  probe,  will  sometimes  become  large  enough  to  receive  a 
goose-quill,  or  even  a  person's  finger.  Accompanying  this  dilata- 
tion, it  is  proper  to  remark,  the  mucous  membrane  of  the  en- 
larged tubes  becomes  thickened  by  the  existing  inflammation  or 
its  effects,  and  loses  its  transparency.  In  another  variety  of  dila- 
tation, the  enlargement  exists  in  a  single  spot,  so  as  to  form  a 
cavity  at  that  spot.  This  cavity  is  sometimes  of  the  size  of  a 
chestnut.  In  this  case,  as  in  the  first,  the  mucous  membrane  is 
generally  thickened.  A  third  variety  consists  in  there  being  a 
series  of  such  cavities.  In  this  case,  the  coats  are  sometimes 
thin,  the  dilatation  being  the  result  of  weakness  and  pressure,  not 
accompanied  with  or  preceded  by  much  active  inflammation.  As 
the  consequence,  the  disease  is  attended  with  more  debility  than 
the  other  varieties :  and  almost  any  increase  of  respiration  pro- 
duces dyspnoea. 

Generally,  in  the  different  cases,  there  is,  to  a  greater  or  less 
extent,  a  condensation  of  pulmonary  tissue  around  the  dilated 
bronchi.  This  is  caused  by  a  deposit  of  new  matter,  essentially 
in  the  sarne  way  as  all  granulation  structures  are  formed.  It  is 
usually  regarded,  however,  as  more  albuminous  or  less  highly 
organized,  than  are  ordinary  deposits  on  serous  membranes.  It  is 
more  like  the  secretion  from  the  mucous  membrane  of  the 
trachea  in  croup. 

The  other  class  of  lesions  to  which  the  bronchi  are  subject, 
and  to  which  I  have  referred,  consists  of  cases  in  which  the 
walls  of  the  tubes  become  thickened  and  the  caliber  diminished. 
In  these  cases,  if  there  is  a  secretion,  it  is  essentially  the  same  as 
that  of  croup.  It  is  the  result  of  active  preceding  inflammation, 
not  attended  by  the  violence  which  produces  enlargement.  The 


MORBID    CHANGES    IN   THE    BRONCHI.  175 

albuminous  deposit  may  completely  obliterate  the  canal  of  a  tube  ; 
and  when  it  does,  it  is  sometimes  called  a  bronchial  polypus. 
The  tubal  cavity,  however,  may  be  blocked  up,  by  simple  in- 
flammation, which,  for  the  time  being,  thickens  the  walls.  In 
the  former  case,  the  obstruction  is  permanent,  unless  removed  by 
ulceration  or  absorption,  as  is  the  deposit  in  pneumonitis.  In  the 
latter  case,  the  difficulty  vanishes  with  the  subsidence  of  the 
inflammation. 

DIAGNOSES. — In  that  variety  of  dilatation  in  which  the  enlarge- 
ment extends  equally  throughout  a  tube  or  tubes,  the  air  does  not 
so  reverberate  as  to  give  cavernous  respiration.  Of  course,  the 
sound  is  only  the  shrill  bronchial ;  and  the  character  is  rendered 
full  and  marked,  in  proportion  to  the  degree  of  inflammation  and 
induration  in  and  around  the  tubes.  When  the  enlarged  tubes 
are  loaded  with  mucus,  we  have,  of  course,  the  mucous  rale ;  or, 
in  case  some  of  the  smaller  tubes  are  enlarged  to  those  of  me- 
dium size  only,  we  then  have  in  them  the  sub-crepitant  rale. 
The  respiration  being  the  shrill  bronchial,  the  sound  of  the  voice, 
heard  over  the  enlarged  tubes,  will  be  that  of  bronchophony. 

In  the  second  variety,  and  in  the  third,  we  have  distinct 
cavernous  respiration  and  pectoriloquy  ;  inasmuch  as  a  cavity  and 
cavities,  in  these  cases,  are  distinctly  formed.  Or  when  these 
cavities  are  loaded  with  mucus,  we  necessarily  have  the  gurgling 
rale. 

In  all  cases,  in  which  there  is  appreciable  induration  of  the 
pulmonary  tissue  around  the  dilated  tubes,  we,  of  course,  have 
dullness  on  percussion,  much  the  same  as  in  pneumonitis. 

The  discrimination  of  this  lesion  from  pneumonitis  is  generally 
easy.  In  pneumonitis,  the  progress  of  the  disease  soon  changes 
the  character  of  the  sounds  heard.  In  dilatation  of  the  tubes, 
they  remain  longer  unchanged.  In  phthisis,  sometimes  the 
symptoms  of  the  disease  are  more  nearly  like  those  of  dilatation. 
In  phthisis,  generally  the  cough,  the  fever,  the  emaciation,  and 
other  symptoms  will  sufficiently  characterize  the  disease  ;  where- 
as, in  dilatation  of  the  tubes  simulating  tuberculous  cavities,  there 
are  generally  marked  evidences  of  the  existence  merely  of  bron- 
chitis, Chronic  bronchitis,  however,  dilatation  of  tubes,  and 


176  THORACIC    DISEASES. 

tubercles  in  the  lungs  may  all  exist  simultaneously,  and  so  render 
the  diagnosis  obscure.  When  the  dilated  tubes  are  in  the  supe- 
perior  lobe  of  a  lung,  the  tissue  of  that  lung  may  break  down 
and  form  a  tuberculous  cavity,  thus  bringing  the  two  kinds  of 
cavities  into  juxtaposition,  or  uniting  both  in  one. 

In  the  second  class  of  lesions,  the  prominent  auscultatory  sign 
is  a  diminution  or  almost  a  cessation  of  the  respiratory  sound, 
over  the  affected  part,  the  effect,  of  course,  being  proportioned  to 
the  degree  of  obstruction  in  the  tubes.  The  bronchial  cavity 
may  be  even  entirely  obliterated  in  some  parts,  and  then  the 
respiration  in  those  parts  will  be  entirely  wanting.  When  the 
obstruction  is  from  inflammation  and  not  from  a  deposit  of  albu- 
minous matter,  the  absence  of  the  respiratory  sound  is.  of  short 
duration.  If  a  collection  of  mucus  assists  the  inflammation  in 
producing  the  obstruction,  the  simple  act  of  coughing  may  par- 
tially restore  the  sound  of  respiration.  When  there  actually  is 
an  adventitious  deposit,  the  absence  of  the  respiratory  sound  will, ' 
of  course,  continue  permanently,  9r  till  that  deposit  is  removed 
by  ulceration  or  absorption. 

The  prognosis  generally,  in  cases  of  morbid  changes  in  the 
bronchi,  is  often  favorable.  Often  a  partial  or  an  entire  cure  may 
be  wrought,  and,  where  it  cannot,  but  the  lesion  continues  una- 
bated, still,  if  not  complicated  with  a  more  serious  affection,  it 
seldom  hastens  very  greatly  the  termination  of  life.  It  weakens 
the  vital  powers,  but  does  not  immediately  arrest  their  action. 

TREATMENT. — The  treatment  to  be  adopted  in  the  cure  of 
morbid  changes  in  the  bronchi  is  not  extensive  nor  difficult. 
But  little  comparatively  can  be  accomplished,  directly,  by  any 
remedial  means.  The  object  to  be  mainly  aimed  at,  is  to  remove 
any  existing  bronchitis  or  other  attending  affection,  and  to 
strengthen  the  powers  of  vitality,  that,  as  far  as  possible,  they  may 
restore  the  parts  to  their  normal  condition. 


PNEUMONITIS.  177 

CHAPTER    V. 

PNEUMONITIS. 

The  term  pneumonitis  is  formed  from  the  Greek  word,  TTVSU^GJV,- 
signifying  a  lung,  by  appending  ilis,  the  usual  termination  to  indi- 
cate inflammation.  Pneumonia,  it  is  true,  is  the  orthography  more 
commonly  adopted;  but,  as  this  is  not  analogical,  I  reject  it. 

Like  bronchitis,  pneumonitis  is  ordinarily  an  acute  and  primary 
disease,  but  has,  at  the  same  time,  several  modifications  of  form, 
which  require  special  consideration.  Its  mode  of  existence  differs 
from  that  of  bronchitis  in  one  important  respect : — it  never  as- 
sumes a  form  so  distinctly  chronic  as  that  which  is  sometimes 
taken  by  bronchitis.  In  illustrating  the  disease,  I  prefer,  for 
brevity's  sake,  to  describe  its  usual  characteristics  under  the  un~ 
qualified  designation  of  pneumonitis. 

SECTION    I. 
PNEUMONITIS. 

PATHOLOGY. — This  disease  is  generally  said  to  consist  in  in- 
flammation of  the  areolar  tissue  of  the  lungs.  But  shall  we  use 
the  terms  parenchyma  and  areolar  tissue  as  synonymous,  and  say 
that  the  inflammation  is  limited  to  that  tissue  ?  To  answer  this 
question  understand ingly,  we  must  first  attend  to  a  few  considera- 
tions in  the  anatomical  structure  of  the  lungs. 

The  ultimate  ramifications  of  the  bronchi  terminate  in  vesicles, 
which  are  arranged  in  lobules, — the  vesicles  of  each  lobule 
communicating  with  one  another,  but  not  with  those  of  other 
lobules.  Each  lobule  is  supplied  with  capillary  blood-vessels, 
which  surround  and  line  the  vesicles  with  a  minute  and  intricate 
plexus,  so  arranged  as  to  form  the  parietes  of  contiguous  cells, 
and  thereby  favor  the  aeration  of  the  contained  blood,  by  expo- 
sing it,  on  both  sides,  to  the  contact  of  the  contained  air.  These 
bronchi,  vesicles,  and  blood-vessels,  together  with  lymphatics  and 
nerves  which  accompany  them,  are  bound  together  by  strong 
23 


178  THORACIC    DISEASES. 

areolar  tissue  ;  and  every  portion  whose  vesicles  are  involuted  as 
described,  constitutes  a  lobule.  Since,  now  the  term  parenchyma 
is  used  to  express  the  substance  of  the  lungs,  it  may,  with  pro- 
priety, be  extended  so  as  to  embrace  not  merely  the  areolar  tissue, 
but  all  these  tissues  united,  so  far  as  they  are  contained  in  and 
constitute  lobules, — particularly  the  areolar  tissue,  the  blood- 
vessels, the  vesicles,  and  the  extremities  of  the  bronchi  termina- 
ting in  the  vesicles. 

The  older  pathologists  have  discussed  the  question,  whether 
pneumonitis  is  really  inflammation  of  the  areolar  tissue  or  only 
of  the  vesicles;  but,  in  view  of  the  anatomy  of  the  parts  as  just 
described,  and  in  the  light  which  is  now  thrown  on  the  nature  of 
inflammation,  it  cannot  for  a  moment  be  doubted  that,  in  this 
disease,  all  the  tissues  in  the  lobules  are  involuted.  Indeed,  post 
mortem  examinations  have  set  the  matter  at  rest ; — it  is  so. 
Bronchitis  is  inflammation  of  the  mucous  or  lining  membrane 
of  the  tubes,  whether  that  inflammation  extends  to  the  extremi- 
ties of  the  tubes  or  not.  Pneumonitis  is  inflammation  extending 
throughout  the  substance  of  the  lung  embracing  every  thing  but 
the  pleura,  which  is  the  external  lining. 

Pneumonitis  may  commence  in  either  of  two  ways.  It  may 
have  its  origin  in  bronchitis, — the  inflammation  on  the  mucous 
tissue  of  the  bronchi,  passing  down  to  the  vesicles  and  thence 
involving  the  other  tissues;  or  it  may  commence  directly  in  the 
tissues  constituting  the  vesicular  structure,  and  extend  to  the 
surface  of  the  lung,  there  implicating  the  pleura,  and  constituting 
pleuro-pneumonitis.  The  pleura  may  even  be  the  part  primarily 
inflamed  ;  and,  from  this,  the  inflammation  may  extend  inward 
upon  the  parenchyma.  When,  in  such  a  case,  the  evidences  of 
inflammation  of  the  pleura  are  more  marked  than  those  of  inflam 
mation  of  the  parenchyma  of  the  lungs,  the  term  pneumo-pleuritis 
has  sometimes  been  employed  to  designate  the  disease,  it  being 
then  intended  to  restrict  the  pleuro-pneumonitis  or  pleuro-pneu- 
monia  to  those  cases  in  which  the  pulmonary  parenchyma  is  most 
affected. 

Unlike  bronchitis,  pneumonitis  is,  almost  always,  attended  with 
considerable  constitutional  disturbance.  The  reason  of  the  dif 
ferencc  is  obvious.  In  bronchitis,  the  bronchial  tubes  are  open} 


PNEUMONITIS.  179 

the  respiration  is  free,  and  the  secretion  into  the  tubes  is  expec- 
torated without  difficulty.  In  pneumonitis,  on  the  contrary,  the 
inflammation  of  the  lobules  not  only  prevents  the  admission  of 
air  into  them,  but  closes  the  bronchial  exit  from  them,  and  con- 
fines the  secretion,  creating  new  degrees  of  disturbance.  The 
failure  of  the  blood  to  be 'properly  arterialized,  therefore,  and  of 
the  secretion  to  be  properly  passed  off,  is  a  double  cause  of  febrile 
action  in  the  system.  It  is  true,  that  in  the  latter  disease,  there 
is,  at  length,  a  copious  expectoration  ;  but  this  is  not  until  the 
secretion  has  been  for  a  time  confined,  and  a  good  deal  of  consti- 
tutional disturbance  has  been  created.  The  failure  in  the  arten'a- 
lization  of  the  blood,  however,  is  doubtless  the  principal  cause  of 
the  febrile  excitement. 

Pneumonitis  is  divided  into  four  stages,  characterized  by  marked 
pathological  changes.  The  first  of  these  I  call  the  stage  of  in- 
filtration. It  has  been  called  the  stage  of  engorgement,  of  con- 
gestion, and  of  inflammation.  The  pathological  condition  of  the 
lung  is  that  of  inflammation,  combined  with  effusion  or  anasarca. 
If  a  portion  of  the  tissue  be  examined,  it  will  be  found  that, 
besides  a  little  mucus  in  the  smallest  tubes,  the  capillaries  are 
loaded  with  blood,  as  in  other  cases  of  inflammation,  and  the 
tissues  are  slightly  softened.  But,  besides  this  condition,  there  is 
also  an  effusion  of  a  reddish  and  turbid  serum.  Evidently,  the 
obstruction  to  the  circulation  produced  in  the  capillaries,  by  what 
is  inflammation  properly  so  called,  gives  origin  to  a  congestion  of 
the  venous  blood  in  the  ramifications  of  the  pulmonary  artery ; 
and,  from  this  congestion,  arises  the  effusion.  Under  these  cir- 
cumstances the  lung  is,  of  course,  of  a  reddish-brown  color,  being 
somewhat  swollen,  pitting  on  pressure,  crepitating  less,  though 
more  friable,  and,  if  incised,  yielding  the  serum  referred  to. 

The  state  of  the  lung  in  the  infiltration  of  pneumonitis  is  near- 
ly indentical  with  that  which  is  very  commonly  found  in  the  pos- 
tero-inferior  portion  of  each  lung  after  death, — especially  with 
those  persons  who  have  died,  after  lung  agony.  In  the-  latter 
case,  there  is,  indeed,  but  little  more  than  the  effects  of  a  stasis 
of  the  blood,  arising  from  position  and  from  weakness  ;  but,  then, 
in  this  active  state  of  inflammation,  there  is  yet  not  so  great  chem- 


180  THORACIC    DISEASES. 

ical  or  vital  change  wrought  in  the  blood  as  to  make  any  appreci- 
able difference. 

The  pathology  of  this  stage  of  pneumonitis,  being  so  simple 
and  easily  understood,  ought  not  to  be  overlooked  ;  and  yet  many 
practitioners  and  some  professed  pathologists  have  failed  to  have 
any  definite  perception  of  the  real  condition  of  things. 

The  second  stage  of  pneumonitis  I  call  that  of  hepatization. 
It  has  also  been  called  red  hepatization,  red  softening,  and  hard- 
ening. The  reasons  of  these  different  names  are  found  in  the 
characteristic  condition  of  the  lung  in  this  stage.  I  need  not 
stop  to  explain  them,  farther  than  to  say,  that  hepatization  is  a 
term  derived  from  rjcap,  signifying  liver.  Hepatization,  therefore, 
means  the  being  made  like,  or  the  resemblance  to  liver;  and  this 
resemblance  is  the  most  striking  feature  in  the  appearance  of  the 
lung  in  this  stage. 

The  pathology  of  the  affected  part  is  really  the  thing  impor- 
tant to  be  understood.  In  treating  of  inflammation  and  the  repar- 
ative  process,  I  have  shown  the  pathology  of  each,  and  the  con- 
nection of  one  with  the  other.  I  have,  also,  in  another  place  re- 
marked, that  there  is  sometimes  a  process  of  exudation,  from 
mucous  tissues,  following  their  inflammation,  and  resembling  the 
reparative  process,  but  forming  a  structure  that  is  but  imperfectly 
organized.  Consider,  now,  that  the  first  stage  of  pneumonitis  is 
substantially  one  of  inflammation  ;  and  that,  succeeding  that  must 
be  substantially  the  condition  produced  by  the  establishment  of 
the  reparative  process.  So  far,  however,  as  the  exudation  process 
takes  place  within  the  smallest  bronchial  tubes  and  the  vesicles, 
it  is  possible,  that  the  deposit  may  not  be  of  the  most  plastic  or 
organized  kind.  Be  that  as  it  may,  the  process,  as  it  ordinarily 
succeeds  inflammation,  is  always  the  granulating  or  partially  chem- 
ical process  ; — it  is  that  process,  the  deposit  of  which  is  removed, 
as  the  perfect  structure  is  afterwards  more  slowly  formed.  To 
suppose,  then,  that  a  hepatized  lung  returns  to  its  normal  condi- 
tion is  to  suppose  merely,  that  the  granulation  structure  is  removed, 
by  interstitial  absorption  or  otherwise,  and  that  the  ordinary  form 
of  the  reparative  process  is  again  established. 

Havjng  thus  asserted  what  hepatization  is,  let  us  see  how  the 
pathological  appearances  will  sustain  the  assertion.  In  passing 


PNEUMONITIS.  181 

from  the  first  to  the  second  stage,  the  lung  generally  assumes  a 
somewhat  brighter  hue,  like  that  of  liver  and  nearly  like  that  of 
granulations  generally.  It  appears  swollen  and  heavy.  Indeed, 
while  in  the  first  stage,  as  well  as  in  health,  pulmonary  tissue  is 
lighter  than  water,  but  any  portion,  in  the  second  stage,  separated 
from  the  rest,  will  sink  in  water.  It  does  not  crepitate  ;  and, 
when  pressed  by  the  fingers,  feels  solid  like  liver.  When  the 
substance  is  incised,  a  smooth  surface  is  exhibited ;  usually,  how- 
ever, having  some  red  shades  darker  than  others.  In  being  torn, 
its  tissues  are  found  to  be  somewhat  softened,  that  is,  its  particles 
are  less  adherent  than  in  health,  and,  when  pressed,  a  slightly  vis- 
cid and  reddish  fluid  will  exude  in  a  moderate  quantity.  The  in- 
cised surface,  being  carefully  examined,  generally  shows  itself 
studded  with  small,  red,  and  rounded  granulations,  which  are  the 
abnormal  contents  of  the  vesicles.  In  some  cases,  however,  the 
granulations  seem  to  be  packed  so  closely  as  to  coalesce  and  not 
show  their  distinctive  character. 

In  all  this,  there  is,  I  believe,  nothing  inconsistent  with  my 
position,  but  much,  at  least,  to  confirmjt.  To  my  own  mind,  at 
any  rate,  these  and  other  evidences  combined  are  conclusive.  Let 
then  the  pathology  of  this  stage  be  distinctly  understood. 

The  third  stage  of  pneumonitis  I  call  that  of  suppuration.  It 
has.  also,  received  the  names  of  gray  softening,  gray  hepatization, 
purulent  infiltration,  and  yellow  hepatization  ;  the  reasons  for  the 
use  of  which  it  is  easy  to  find  in  the  pathological  condition  of 
the  part  affected.  In  this  stage,  the  lung  still  is,  to  a  considerable 
extent  solid,  though  it  is  infiltrated  with  purulent  matter,  diffused 
through  the  areolar  tissue  and  deposited  in  the  vesicles ;  so  that, 
when  any  part  is  incised  and  subjected  to  pressure,  this  matter  ex- 
udes abundantly.  The  lung  is  as  impervious  to  air,  as  in  the  sec- 
ond stage,  and  it  as  readily  sinks  in  water.  On  being  subjected 
to  force,  the  particles  are  found  to  be  less  adherent  than  in  the 
second  stage.  Its  surface,  especially  its  cut  surface,  is  of  a  mar- 
bled appearance, — at  the  early  part  of  this  stage,  being  rather  red 
and  gray,  but,  at  a  later  period,  gray  and  yellow.  The  granular 
appearance  is  not  as  distinct  as  in  the  second  stage,  and  what 
granulations  remain  have  a  yellowish  color.  At  length,  the  tis- 
sue generally  assumes  a  straw  color,  and  is  so  friable,  as,  on  the 


182 


THORACIC    DISEASES. 


slightest  pressure  of  the  finger,  to  break  down  into  a  purulent  de- 
tritus. By  placing  a  portion  of  lung,  in  this  stage,  under  a  stream 
of  water,  all  the  parts  hut  the  bronchial  tubes  wash  away,  and 
leave  those  tubes  free.  When  this  is  done,  it  is  seen,  that  the 
tubes  have  contained  purulent  liquid,  and  that  the  bronchial  mu- 
cous membrane  is  not  so  red  as  it  is  in  the  second  stage. 

The  fourth  stage  of  pneumonitis  I  call  that  of  ulceration.  This 
stage  and  the  third  have  very  commonly,  by  pathologists,  been 
combined  together,  as  one  stage.  Pathology,  however,  affords 
sufficient  reason  for  the  division.  In  this  stage,  an  abscess  or  ab- 
scesses are  formed,  in  the  parenchyma  of  the  affected  lung,  resemb- 
ling an  ordinary  abscess  in  other  tissues  of  the  body;  in  other 
words,  a  portion  of  the  lung  softens  down  and  ulcerates  away,  and 
the  detritus  is  removed  by  expectoration.  Of  course,  a  cavity  or 
cavities  remain  ;  and  this  constitutes  the  prominent  characteristic 
of  this  stage  of  the  disease. 

Pneumonitis  may  be  either  single  or  double  ;  that  is,  it  may  af- 
fect either  one  side  only,  or  both  sides.  If  both  sides  become 
simultaneously  and  extensively  affected,  the  disease  is  almost  nec- 
essarily fatal.  Fortunately  this  condition  but  seldom  occurs.  It 
is  generally  considered,  that  pneumonitis  occurs  much  more  fre- 
quently on  the  right  side  than  on  the  left.  In  my  own  practice, 
I  have  never  kept  any  statistics,  but  my  impression  is,  that  the 
disparity  in  the  number  of  cases  on  each  side  has  not  been  great. 
Again,  authors  tell  us,  that  this  disease,  very  commonly  but  far 
from  uniformly,  commences  at  the  lower  portion  of  the  lung.  An- 
dral's  statistical  representation  is,  that,  of  eighty-eight  cases  of 
pneumonia,  he  found  the  inflammation  affected  the  inferior  lobe 
forty-seven  times,  the  superior  lobe  thirty,  and  the  whole  lung  at 
once  eleven.  I  know  not  what  has  occurred  with  other  practi- 
tioners and  in  other  countries;  but,  in  my  own  practice  in  this 
country,  I  have  never  found  a  solitary  case  in  which  idiopathic  or 
active  primary  pneumonitis  did  not  begin  in  the  lower  half  of  the 
lung.  If  on  the  right  side,  it  may,  perhaps,  affect  the  lower  por- 
tion of  the  middle  lobe,  simultaneously  with  the  inferior  lobe ; 
but  I  do  not  believe  that,  in  this  country,  it  ever  commences  in  the 
superior  lobe,  or  seizes  on  that  to  the  neglect  of  the  inferior.  If 
the  case  be  a  severe  one,  it  sometimes  advances  upward  till  it  in- 


PNEUMON1TIS.  183 

volves  the  whole  lung;  but,  in  most  instances,  it  is  limited  to  the 
lower  half. 

DIAGNOSIS.— As  to  some  of  the  constitutional  and  rational  symp- 
toms, I  remark  that  quite  frequently  pneurnonitis  commences  with 
a  chill  and  shivering,  which  lasts  for  an  hour  or  more,  and  is  fol- 
lowed by  an  abnormal  amount  of  heat  and  an  increased  fullness 
and  frequency  of  pulse  ;  in  other  words,  by  inflammatory  fever. 
Indeed,  in  this  case,  the  pulse  generally  ranges  from  ninety  to  one 
hundred  and  twenty  per  minute,  arid  is  of  considerable  strength  ; 
though,  in  an  advanced  period  of  the  disease,  it  may  be  even  more 
rapid  and  may  be  comparatively  feeble.  Sometimes,  however,  the 
disease  comes  on  more  gradually  and  insidiously,  being  introduced 
by  the  earlier  existence  of  bronchitis  ;  that  is,  inflammation  com- 
mences on  the  mucous  membrane  of  some  of  the  bronchial  rami- 
fications, arid  passes  to  the  smallest  tubes,  the  vesicles  and  the  in- 
terstitial textures.  Of  course,  the  febrile  symptoms  are  less  rapid- 
ly developed,  though  they  are  essentially  the  same. 

In  the  former  case,  the  disease  is  generally  attended  by  a  pecu- 
liar lancinating  pain  usually  termed  a  stitch  in  the  side  ; — in  the 
latter,  this  pain  may  or  may  not  be  experienced.  When  it  exists, 
it  is  of  that  peculiar  character  which  marks  inflammation  of  a 
serous  tissue ;  and  it  is  generally  believed  to  arise  from  inflamma- 
tion of  the  pleura.  In  other  words,  it  is  supposed,  that  the  cases 
of  pneumonitis  which  are  attended  by  it,  are  all  really  cases  of 
pleuro-pneumonitiSj — the  pleura,  as  well  as  the  pulmonary  paren- 
chyma, being  involved.  It  is  supposed  that  inflammation  of  the 
parenchyma  alone,  gives  no  pain.  Inasmuch,  however,  as  blood- 
vessels contain  serous  tissue,  and  pervade  the  lungs,  I  do  not  con- 
sider it,  by  any  means,  certain,  that  all  pain  in  this  disease,  is  lim- 
ited to  cases  of  pleuro-pneumonitis ;  though,  doubtless,  all  very 
severe  and  lancinating  pain  is  so  limited.  The  location  of  the 
pain  is  generally  on  a  level  with,  or  a  little  below  the  nipple  on 
the  affected  side.  It  is  aggravated  by  the  act  of  coughing,  by  a 
full  inspiration,  by  certain  changes  of  posture,  especially  if  they 
are  suddenly  made,  by  percussion,  and  by  ordinary  pressure,  cither 
on  the  ribs  or  on  the  intercostal  spaces.  It  is  the  most  severe,  at 


184  THOKACIC    DISEASES. 

the  early  part  of  the  disease,  and  it  gradually  declines.  It  ceases 
entirely,  sometime  before  the  disease  passes  away.  * 

The  cough  of  pneumonitis  is  at  least  generally  short  and  sup- 
pressed. The  patient  being  unable  fully  to  inflate  his  lungs,  air 
is  not  expired  in  sufficient  amount  to  produce  loudness  of  sound. 
Besides,  the  pain  caused  by  coughing  induces  him  voluntarily  to 
repress  the  act  as  far  as  he  conveniently  can.  As  the  disease 
passes  into  the  second  stage,  the  cough  becomes  loose  and  the 
expectoration  somewhat  abundant.  The  .character  of  the  sputa 
changes  with  the  different  stages ;  but  the  looseness  of  the  cough 
and  the  pureness  of  the  expectoration  continue,  till  the  disease 
has  very  far  receded. 

The  sputa  at  first  do  not  differ  much  from  those  of  ordinary 
bronchitis ;  but,  as  the  disease  passes  into  the  second  stage,  they 
become  viscid  and  rusty,  and  constitute  the  most  distinctly 
pathognomonic  sign  of  this  stage.  They  are  made  up  of  thick 
adhesive  mucus  secreted  into  the  bronchial  tubes,  and  of  blood 
discharged  from  the  hepatized  lung.  The  viscidity  is  so  great, 
that  the  cup,  even  when  containing  a  considerable  quantity  of 
the  sputa,  may  be  nearly  or  quite  inverted,  without  parting  with 
its  contents.  The  mucus  and  the  blood  are  not  rarely  so  mixed, 
that  the  one  shall  be  streaked  with  the  other  ;  but  they  are  fully 
incorporated,  the  one  with  the  other,  so  as  to  present  a  uniform 
color  throughout,  and  that  is  very  nearly  the  color  of  iron  rust. 
This  peculiarity  is  found  in  no  other  dissase  whatever,  and  in 
none  but  the  second  stage  of  this  disease.  Of  course,  it  unerringly 
marks  this  disease  and  this  stage  of  it.  In  this  stage,  a  decided 
increase  in  the  quantity  of  the  sputa  is  evidence,  that  the  disease 
has  begun  to  retrograde. 

In  the  third  stage,  the  sputa  are  more  purulent,  and  generally 
more  abundant  than  in  the  second.  When  the  disease  recedes 
from  this  stage,  the  sputa  become  thinner  and  less  purulent. 

Asa  cavity  forms  constituting  the  fourth  stage,  a  large  quantity 
of  decided  purulent  sputa  are  discharged  in  a  short  time ;  but,  if 
recovery  is  effected,  the  discharge  afterwards  or  much  the  same, 
as  in  recovery  from  the  third  stage. 

The  frequency  of  respiration  in  this  disease  is  proportioned 
somewhat  to  the  extent  of  the  inflammation.  Difference  of  tern- 


PNEUMONITIS.  185 

perament,  it  is  true,  will  make  considerable  difference  in  the  case, 
• — a  nervous  person  being  liable  to  considerable  excitement  from 
the  irritability  of  the  nervous  system.  But,  aside  from  incidental 
causes,  the  smaller  the  quantity  of  air  which  enters  the  lungs  at  one 
inspiration  to  arterialize  the  blood,  the  sooner  it  is  necessary  that 
the  inspiration  be  repeated  ;  and  the  vital  powers  are  so  balanced, 
that,  when  the  former  does  not  operate  to  produce  a  large  inspira- 
tion, it  does  operate  to  produce  more  than  one  short  one.  If 
there  is  but  slight  disease  on  one  lung  only,  the  respiration  is  not 
-greatly  quickened.  If  the  whole  of  the  inferior  lobe  is  involved, 
the  inspirations  will  be  from  forty  to  fifty  per  minute ;  and,  when 
the  greater  portion  of  the  lung  is  involved,  the  respirations  are 
liable  to  be  from  fifty  to  sixty  per  minute.  If  both  lungs  are 
involved,  or  the  difficulty  has  become  of  a  serious  character,  the 
respirations  may  be  even  more  frequent. 

The  mode  of  respiration  in  pneumonitisis  somewhat  peculiar. 
Usually,  it  is  performed  chiefly  by  the  side  of  the  thorax  which  is 
not  diseased.  When,  however,  a  severe  case  has  continued  for  a 
considerable  time,  the  ribs  cease,  to  a  great  extent,  to  be  moved, 
and  the  respiration  becomes  mainly  abdominal. 

The  flush  of  the  countenance  in  pneumonitis,  also,  indicates 
the  disease.  It  is  sometimes  a  circumscribed  and  circular  flush 
on  one  cheek.— generally  that  on  the  side  of  the  affected  lung,—' 
and  sometimes  a  similar  flush  on  both  cheeks  at  the  same  time. 
Sometimes,  too,  the  whole  face  is  flushed  ;  and  the  color  varies, 
from  that  of  arterial  to  that  of  venous  blood.  This  variety 
depends  essentially  on  the  amount  of  obstruction  which  the 
blood  receives  in  passing  through  the  lungs. 

Dilatation  of  the  nostrils  in  each  inspiration  is  an  indication  of 
this  disease,  depending  upon  the  existing  dyspnosa  and  propor- 
tioned to  its  extent. 

The  peculiar  failure  of  the  physical  strength  is  another  sign  of 
pneumonitis  worthy  of  some  regard.  The  patient  will  often  find 
himself  too  much  enfeebled  to  sit  up,  at  the  commencement  of 
this  disease,  even  when  it  is  not  very  severe,  and  before  the  phy- 
sical or  other  signs  have  fully  disclosed  its  nature. 

The  physical  signs  of  pneumonitis  vary,  in  a  marked  degree, 
with  the  successive  stages.     In  the  first  stage,  the  most  important 
24 


186  THORACIC    DISEASES. 

sign  is  the  crepitant  rale.  This,  indeed,  when  heard,  is  pathogno- 
monic  of  the  disease  in  this  stage  ;  but  it  never  continues  but  a 
short  time,  and  commonly  passes  away  before  the  patient  considers 
himself  sick  enough  to  call  a  physician.  Besides,  if  the  inflam- 
mation is  only  deep-seated  and  does  not  involve  the  surface  of  the 
lung,  either  the  crepitus  does  not  exist,  or  the  healthy  respiration 
from  the  surface  prevents  its  being  heard.  Probably  the  vesicles 
and  smallest  tubes  are  so  compressed  that  air  cannot  pass  through 
them  to  produce  the  rustling.  In  this  stage,  the  bronchial  respira- 
tion of  health  is  but  slightly  altered.  It  sometimes  partakes 
appreciably  of  the  shrill  bronchial  character,  in  consequence  of 
the  interruption  of  the  vesicular  sound,  and  the  slight  hardening 
given  to  the  lung  by  its  infiltration.  The  latter  condition  is  also 
indicated  by  a  slight  modification  of  bronchophony  from  the  con- 
dition of  health.  Percussion  yields  nearly  ihe  resonance  of  health. 
The  infiltration  and  the  displacement  of  the  air  from  the  tubes 
may  render  the  sound  slightly  dull,  but  never  considerably  so. 

In  the  second  stage,  the  physical  signs  are  marked  and  unerring. 
There  is  no  longer  any  crepitant  rale,  for  the  smallest  tubes  are 
completely  blocked  up,  or,  for  the  time  being,  obliterated ;  but 
the  hepatization  of  the  lung  gives  the  shrill  bronchial  respiration 
in  its  most  intense  degree.  The  vesicular  sound  is  not  made, 
and  therefore  does  not  modify  the  bronchial ;  but  the  consolida- 
tion of  the  lung  conveys  the  most  perfectly  to  the  ear  the  sound 
made  in  the  medium-sized  and  largest  tubes.  As  primary  or 
idiopathic  pneumonitis  affects  primarily  and  mainly  the  lower 
portion  of  the  lung,  we  have  the  shrill  bronchial  respiration  the 
most  marked  at  the  root  of  the  lungs.  The  longest  tubes,  of 
course,  make  the  fullest  sound;  and,  if  the  pulmonary  tissue 
around  them  is  completely  hardened,  the  sound  approaches  in 
character  to  tracheal  or  cavernous  respiration.  The  term  tubal 
has  sometimes  been  employed  to  express  the  intensity  of  this 
sound.  Of  course,  that  is  using  the  term  in  a  sense  different  from 
that  in  which  I  employ  it.  Sometimes,  especially  if  the  patient 
breathes  rapidly,  the  crepitant  rale  may  be  heard  coexisting  with 
the  bronchial  respiration  ;  but  that  is  because,  as  the  inflammation 
extends,  a  portion  of  the  lung  having  begun  more  recently  to  be 
affected,  is  only  in  the  first  stage  of  the  disease,  while  the  more 


PNEUMONITIS.  187 

prominent  portion  has  reached  the  second.  In  such  a  case,  the 
crepitation,  extending  a  little  farther  from  the  vesicles  into  the 
tubes  than  is  commonly  done,  is  not  of  the  most  delicate  charac- 
ter, and  is  heard  somewhat  in  trains  like  the  sound  of  wet  gun 
powder,  in  those  portions  of  the  lungs  which  are  infiltrated  but 
not  solidified.  In  the  second  stage  of  the  disease,  the  induration 
of  the  lung  also  gives  the  most  perfect  and  extended  bronchophony. 
No  other  disease  can  well  imitate  the  shrill  bronchial  respiration 
and  the  bronchophony  of  pneumonitis.  On  percussion  in  this 
stage,  we  usually  find  the  greatest  dullness  which  can  result  from 
any  cause,  except  the  presence  of  a  liquid,  and  it  is  nearly  or 
quite  equal  to  that.  I  once  knew,  however,  one  case  of  pneu- 
monitis of  the  left  lung,  which  resulted  fatally,  and  which,  for 
several  days  before  death,  gave  the  resonance  of  pneumothorax. 
The  autopsy  revealed  a  large  empty  space  between  the  parietes 
of  the  thorax  on  the  left  side  and  the  lung,  though  the  latter  was 
extensively  hepatized.  The  lung  was  firmly  held  or  crowded 
back  against  the  spine  and  posterior  part  of  the  ribs.  There  was, 
however,  evidence  that  pneumothorax  complicated  the  disease, 
during  the  Jast  few  days  of  the  patient's  life. 

When  the  symptoms  now  described  indicate  the  several  stages 
of  pneumonitis,  if  the  patient  coughs, — and  we  may  direct  him  to 
do  it, — the  shrill  bronchial  sound  will  become  more  marked,  and 
the  air  will  be  driven  so  forcibly  into  such  of  the  swollen  tubes 
as  are  not  entirely  closed  as  to  produce  a  peculiar  modification  of 
the  crepitant  rale. 

In  the  third  stage,  the  shrill  bronchial  respiration  and  the 
bronchophony  of  the  second  stage  have  nearly  or  quite  passed 
away.  When  suppuration  has'  only  begun,  the  lung,  it  is  true, 
has  not,  to  a  great  extent,  softened  ;  but  there  is  a  free  muco- 
purulent  discharge  into  the  bronchi.  This  so  interrupts  the 
passage  of  air  as  to  give  origin  to  the  mucous  and  the  sub- 
crepitant  rales  in  the  largest  and  the  medium-sized  tubes,  while, 
by  lubricating,  as  well  as  by  obstructing  the  bronchi,  it  prevents 
the  characteristic  bronchial  sound  of  the  respiration  and  of  the 
voice.  Percussion  in  this  stage  remains  flat  ;  that  is,  essentially 
as  dull  as  in  the  second  stage.  For,  though  the  lung  has  actually 
begun  to  soften,  and  some  of  the  smaller  bronchial  orifices  before 


188  THORACIC    DISEASES. 

closed  are  opening,  yet  their  orifices  are  filled  with  purulent  mat- 
ter, and  will  give  to  percussion  as  perfect  dullness  as  the  more 
complete  hepatization  would  give.  It  is  proper  here  to  remark, 
that  even  when  a  considerable  portion  of  the  affected  part  of  the 
lung  is  in  the  third  stage  of  the  disease,  another  portion  may  be 
in  the  second,  and  some  portion  still  in  the  first  stage  ;  and,  hence, 
we  may  at  some  points  get  the  sounds  of  the  second  stage,  and, 
by  requiring  the  patient  to  respire  strongly,  we  may  even  hear 
something  of  the  crepitant  rale  indicative  of  the  existence  of  the 
first  stage  in  still  other  portions. 

In  the  fourth  stage,  when  the  cavity  that  is  formed  is  partially 
filled  with  miico-purulent  matter,  we  have  the  gurgling  rale. 
When  the  matter  is  expectorated,  as  sometimes  after  a  hard 
coughing  especially  it  is,  we  have  cavernous  respiration.  Percus- 
sion over  the  cavity  will  be  more  or  less  resonant;  and,  if  the 
cavity  be  near  the  surface,  we  sometimes  get  the  cracked-pot 
sound.  Percussion,  away  from  the  cavity,  but  over  the  diseased 
portion  of  the  lung,  remains  flat. 

This  stage  of  the  disease  but  seldom  occurs ;  but  when  it  has 
taken  place  at  one  point,  other  portions  of  the  diseased  part  will, 
of  course,  be  in  a  less  advanced  condition,  and  will  present 
symptoms  corresponding  with  the  stage  in  which  they  are  found. 

There  is,  in  pneumonitis,  when  it  is  not  fatal,  what  may  be 
called  a  period  of  recovery  ;  but  the  signs  of  return  to  health 
vary  according  to  the  stage  which  it  has  reached  and  from  which 
it  has  to  retrace  its  steps.  If  it  has  gone  no  further  than  the 
second  stage,  its  return  to  the  first  is  indicated  by  the  return  of 
the  crepitant  rale  which,  however,  is  of  a  looser  and  more  moist 
character  than  it  was  at  the  first  "commencement  of  the  disease. 
As  this  subsides,  it  is  gradually  replaced  by  the  vesicular  sound 
of  health,  though  often  a  considerable  time  elapses  before  the 
respiration  becomes  entirely  normal.  The  shrill  bronchial  char- 
acter of  the  respiration  and  the  dullness  of  percussion  do  not  sud- 
denly cease.  The  latter,  especially,  remains,  in  a  degree,  till 
most  of  the  other  symptoms  have  passed  away,  and  the  health  of 
the  patient  is  nearly  restored.  The  granulation  process  involved 
in  the  hepatization  of  the  lung  has  to  be  removed ;  and  this  must 
be  done  either  by  interstitial  absorption  or  by  ulceration. 


PNEUMONITIS.  189 

When,  however,  the  return  to  health  is  from  the  third  stage, 
the  mucous  rale,  produced  by  the  mucus  and  pus  in  the  bronchi, 
is  the  first  sign  of  recovery ;  the  former  being  a  secretion  from 
the  tubes,  and  the  latter  resulting  from  the  ulceration  of  the  tissue 
involved.  The  creation  and  discharge  of  this  muco-purulent 
matter  promote  health.  As  the  disease  recedes,  the  liquid  be- 
comes less  purulent  and  more  mucous,  until  a  normal  condition 
is  restored. 

If  health  is  restored  from  the  fourth  stage,  the  parts  involved 
in  the  abscess  have  to  be  cicatrized.  While  this  is  taking 
place,  there  is  a  free  formation,  and  of  course  a  free  discharge  of 
pus  ;  but  after  the  cavity  is  healed,  and  the  abnornal  formation  in 
other  parts  of  the  lung  is  removed, 'the  liquid  passing  into  the 
tubes  becomes  entirely  mucous,  and  the  normal  condition  is  pro- 
duced as  in  the  third  stage.  If,  however,  the  patient  sinks  under 
the  influence  of  the  disease,  at  whatever  stage  the  evidences  of 
approaching  death  appear,  the  symptoms  generally  will  be  aggra- 
vated. The  dyspnoea  will  be  increased,  the  pulse  will  be  quick- 
ened and  rendered  feeble,  expectoration  will  become  difficult,  the 
countenance  will  be  haggard, — in  a  word,  it  will  be  seen  that  vi- 
tality is  yielding  its  control. 

The  prognosis  in  a  case  of  pneumonitis,  varies  according  to  the 
circumstances  of  its  severity,  the  age  of  the  patient,  his  general 
previous  health,  the  time  at  which  proper  treatment  is  commenced, 
&c.  When  pneumonitis  is  sthenic  in  character,  the  circumstances 
under  which  it  exists  not  being  unfriendly,  the  prognosis  is  favor- 
able. But,  when  the  disease  is  complicated  with  other  grave  af- 
fections, when  the  constitution  is  worn  out  with  previous  disease 
or  with  age,  when  suitable  treatment  in  suitable  time,  is  not  adopt- 
ed, or  when  the  disease  for  some  unknown  reason  assumes  its  se- 
verest form,  the  prognosis  is  unfavorable.  Dr.  Gerhard  says,  "  A 
mild  case  of  frank  pneumonia,  without  treatment,  usually  lasts 
from  ten  to  twenty-one  days ;  but,  if  it  has  reached  the  third 
stage,  it  will  last  much  longer."  He  also  says,  "If  you  treat  it 
from  the  first,  you  may  frequently  produce  a  partial  destruction  of 
the  disease,  and  shorten  somewhat  its  duration.  When  the  dis- 
order terminates  fatally,  death  usually  occurs  early  in  the  third 
stage,  or  just  in  the  passage  from  the  second  to  the  third  stage. 


190  THORACIC    DISEASES. 

This  stage  is  reached  at  different  periods, — sometimes  in  three  or 
four  days,  but  generally  about  the  beginning  of  the  second  week." 
When  properly  treated  from  the  first, — if  I  may  decide  by  the  re- 
sults of  my  own  practice, — the  disease  usually  forms  a  crisis  or 
begins  to  amend, — if  amendment  takes  place, — in  about  one  week 
from  the  time  of  the  attack.  After  this  about  the  same  length  of 
time  will  be  spent  in  convalescence ;  though  the  patient  often  re- 
quites in  this  time,  but  little  medical  attendance.  Some  cases,  of 
course,  are  liable  to  be  longer  protracted.  In  the  few  cases  which 
have  proved  fatal  under  my  charge,  death  has  occurred  at  a  peri- 
od of  from  one  to  two  weeks. 

TREATMENT. — As  simple  sthenic  pneumonitis  consists  primarily 
in  the  local  inflammation,  and  the  febrile  action  is  merely  symp- 
tomatic, the  nature  of  the  treatment  to  be  adopted  is  plainly  indi- 
cated. The  removal  of  the  inflammation  is  the  thing  to  be  ef- 
fected. And,  as  inflammation  commences  in  capillary  congestion 
and  is  sustained  by  it,  the  blood  must  be  determined  away  from 
the  lungs, — in  other  words,  the  circulation  must  be  equalized.  In 
consequence  of  the  nervous  '  sympathy  between  the  stomach  and 
the  circulation,  and  the  tendency  of  emesis  to  relax  the  cutaneous 
vessels,  ordinarily  a  simple  emetic, — for  which  nothing  is  better 
than  a  proper  preparation  of  lobelia  inflata, — is  desirable  at  the  out- 
set. After  this,  for  a  depurative  effect,  a  due  action  of  the  bow- 
els should  be  sustained,  though  drastic  purgatives  should  be  avoid- 
ed. As  an  aperient,  no  agent  better  suits  most  constitutions  than 
leptandria  virgjnica,  which  may  be  given  in  a  warm  infusion.  If 
this  is  objectionable  on  account  of  the  unpleasantness  of  the  dose, 
the  leptandrin  may  be  substituted,  its  aperient  power  being  in- 
creased by  the  addition  of  a  small  quantity  of  podophyllin  : — say 
take  of  leptandrin  three  parts,  and  of  podophyllin  one  part.  If  to 
this,  one  part  of  pulverized  capsicum  be  added,  its  stimulating  ef- 
fect will  render  the  operation  milder  and  more  recuperative.  Let 
the  quantity  be  such  as  barely  and  easily  to  evacuate  the  alimen- 
tary canal. 

The  stomach  and  bowels  having  received  this  attention,  expec- 
toration and  diaphoresis  should  be  particularly  attended  to.  For 
this  purpose,  put  the  patient  under  the  influence  of  an  expector- 


PNEUMON1TIS. 


191 


ant  and  diaphoretic  powder.  This  may  be  composed  of  the  com- 
mon fever  powder  and  such  expectorant  articles,  as  ictodes  foctida, 
arum  triphyllum,  and  sanguinaria  canadensis.  I  prefer  to  have  the 
whole  taken,  in  infusion,  every  four  hours.  I  also  give  a  pill  of 
lobelia  extract,  every  four  hours, — interchanging  it  with  the  fever 
powder,  and  giving  one  two  hours  from  the  time  of  taking  the 
other.  Or  in  place  of  the  pill,  one  fluid  dram  of  the  com- 
pound sirup  of  lobelia  and  sanguinaria  may  be  given.  Demul- 
cent drinks,  as  a  mucilage  of  ulmus  fulva,  gum  acacia,  and  the 
like,  are  of  service.  Nervines  to  quiet  the  nervous  system,  if 
necessary,  are  serviceable ;  but  narcotics  are  injurious.  They 
suppress  the  cough,  but  do  it  by  deadening  nervous  energy,  in- 
stead of  by  removing  its  cause  ;  and  it  must  be  remembered,  that, 
in  this  instance,  the  cough  is  eminently  excretory,  and  not  irri- 
tative. 

For  external  local  applications,  if,  especially  internal  heat  affects 
the  thorax  externally,  nothing  is  more  directly  serviceable  than  the 
application  of  cold  wet  cloths  over  the  affected  lung, — they  being 
wet  anew  as  often  as  they  become  warm.  If  the  symptomatic 
fever  is  considerable,  a  more  extensive  application  of  wet  cloths 
to  the  surface,  or  even  the  pack  sheet  will  be  of  service. 

Various  other  agents  of  a  nature  similar  to  those  described,  may 
be  employed  with  a  similarly  beneficial  effect.  But,  whatever  be 
the  articles  employed,  they  should  fulfil  the  indications  above 
given,  without  a  depressing  effect  on  the  vital  powers. 

If  the  patient  fails  in  due  time  to  convalesce,  and  the  disease 
assumes  some  new  phasis,  a  corresponding  modification  of  treat- 
ment will,  of  course,  be  required. 

[To  overcome  the  fever,  I  depend  on  continued  and  increasing 
nausea,  terminating  in  emesis.  In  the  beginning  of  the  disease, 
especially  in  strong  constitutions,  the  extract  pill  should  be  freely 
given,  and  a  decided  impression  made  upon  the  circulation  of  the 
blood.  Many  times  by  a  thorough  application  of  this  remedy, 
together  with  the  application  of  wet  cloths  to  the  chest,  the  dis- 
ease may  be  completely  arrested.  If  called  in  the  first  stage.  I 
believe  that  the  physician,  with  these  means  and  other  accessory 
treatment,  can  in  most  cases  stop  its  progress.  C.] 


192  THORACIC    DISEASES. 

SECTION  II. 
ASTHENIC    PNEUMONITIS. 

Though  pneumonitis,  as  it  is  generally  experienced,  is  a  sthenic 
disease,  yet  it  sometimes  assumes  a  decidedly  asthenic  form.  It 
may  take  this  character  from  the  first,  or  not  till  a  later  period  of 
the  disease.  In  the  third  stage,  especially,  the  disease,  if  it  has 
been  at  all  severe,  almost  necessarily  becomes  somewhat  asthenic, 
though  the  asthenia  is  very  differently  marked  from  that  which 
exhibits  itself  in  the  commencement  of  the  disease.  Pus,  being 
extensively  diffused  through  the  lung  in  the  third  stage,  is  neces- 
sarily, especially  if  expectoration  is  not  perfectly  free,  absorbed  in 
a  measure.  This  produces  a  hectic  effect,  and,  of  course,  is  ex- 
tremely protracted.  Besides,  in  the  formation  of  the  pus,  there 
is  an  expenditure  of  a  good  deal  of  vital  power. 

But  the  asthenic  form  which  pneumonitis  assumes  at  the  outset 
of  the  disease,  has  an  entirely  different  origin.  Its  existence  suppos- 
es some  influence  to  have  been  previously  at  work,  and  to  have 
depressed  the  vital  powers,  before  the  pneumonitis  commenced. 
This  influence  may  belong  to  one  of  three  classes.  It  may  be 
the  effect  of  advanced  age ; — it  may  be  that  of  generally  enfee- 
bled health  ; — or  it  may  be  an  epidemic. 

In  the  first  case,  the  pneumonitis  is  often  characterized  as  that 
of  old  age.  The  principal  difference  between  the  manifestations 
of  the  disease,  in  this  case,  and  when  it  is  of  the  ordinary  sthen- 
ic character,  is,  its  tendency  "  to  become  latent,  that  is,  to  lose  the 
ordinary  functional  signs  of  the  acute  inflammation,  and  to  offer 
merely  the  feebleness  and  prostration  which  occur  in  most  severe 
diseases,  with  little  cough  and  little  or  no  expectoration."  This 
difference  is  an  important  one.  If  the  physician  is  unacquainted 
with  physical  signs,  or  being  acquainted,  does  not  think  to  explore 
the  chest  by  means  of  them,  he  will  fail  to  recognize  the  disease. 
There  may  be  a  dusky  purple  tint  of  the  face,  but  there  is  almost 
nothing  in  the  constitutional  and  the  rational  symptoms  to  point 
oat  the  true  malady.  When,  however,  the  pneumonitis  of  old 
age  is  not  entirely  latent,  it  yet  fails  to  be  as  distinctly  marked  as 


ASTHENIC    PNEUMONITIS.  193 

it  is  in  its  ordinary  sthenic  form.  With  few  pectoral  symptoms, 
it  passes  rapidly  to  the  stage  of  suppuration. 

When  asthenic  pneumonitis  arises  from  the  effect  of  generally 
enfeebled  health,  its  characteristics  are  generally  the  same  as  are 
those  of  the  pneumonitis  of  old  age.  I  have  seen  this  form  of 
the  disease  in  a  person  of  middle  age,  with  whom  it  came  on  so 
clandestinely,  that  its  nature  was  not,  for  several  days,  suspected. 
The  obscurity  of  the  general  symptoms  finally  awakened  the 
thought  of  exploring  the  chest  by  physical  signs  ;  and  the  pathol- 
ogical condition  of  things  was  finally  discovered,  but  not  till  the 
third  stage  was  fully  established. 

Asthenic  pneumonitis,  when  arising  from  either  of  the  above 
named  two  classes  of  influence,  may  exhibit  something  of  the 
viscid  rusty  sputa  of  ordinary  sthenic  pneumonitis  ;  or  these  may 
be  wholly  absent.  The  disease  is  not  usually  recognized  in  sea- 
son for  much  specific  and  appropriate  treatment,  till  the  third  stage 
is  established.  The  prognosis,  in  this  case,  is  doubtful. 

The  treatment  in  this  stage  differs  from  that  of  the  same  stage, 
when  the  disease  retains  the  sthenic  form.  The  expectorants 
given  should  be  of  the  stimulating  class ;  and  even  the  simple 
diffusible  stimulants  and  the  ordinary  tonics  are  indicated.  The 
reason  for  this  treatment  it  will  be  readily  seen,  is  the  necessity 
for  sustaining  the  enfeebled  vital  powers.  Among  the  valuable 
stimulating  expectorants,  are  polygala  senega  and  eupatorium  per- 
foliatum.  A  union  of  stimulant  and  tonic  properties  is  found  in 
myrica  cerifera,  asarum  canadense,  and  aristolochia  serpentaria. 
An  infusion  of  capsicum  and  a  solution  of  carbonate  of  ammonia 
arc  also  effective  as  diffusible  stimulants,  while  they  do  not 
depress  the  system  afterwards,  but  leave  it  more  or  less  sustained. 
Peruvian  bark,  also,  is  a  tonic  suited  to  this  condition  of  disease  ; 
or,  in  place  of  it,  quinine  or  salicine,  in  proper  doses,  may  be  em- 
ployed. 

When  asthenic  pneumonitis  arises  from  an  epidemic  influence, 
or  especially  from  such  an  influence,  combined  with  the  effects  of 
age  and  generally  enfeebled  health,  the  asthenia  is  somewhat  pe- 
culiar, and  the  disease  takes  the  name  of  typhoid  pneumonitis  or 
pneumonia,  or,  as  it  is  commonly  written  technically,  pneumonia 
typhoidcs.  This  character,  may  even  be  assumed  in  the  third 


194  THORACIC    DISEASES. 

stage  of  the  disease,  though  it  begun  as  ordinary  sthenic  pneufnon-* 
itis.  The  positive  effect  of  injurious  drugs  and  the  negative  influ- 
ence of  neglecting  to  rebuke  disease  at  an  early  period,  may,  in 
this  case  as  in  dysenteria,  so  deprave  the  blood  and  reduce  the 
vital  powers,  as  to  get  the  system  into  a  state  similar  to  that  which 
is  produced  by  miasma  or  malaria,  or  whatever  creates  typhoid 
fever. 

Sometimes  pneumonitis  has  characteristics  which  have  given 
rise  to  the  term  bilious.  When  the  disease  is  on  the  right  lung 
especially,  that  the  inflammation  should  extend  to  the  liver  which 
is  separated  from  that  lung  only  by  the  diaphragm,  and  that  it 
should  affect,  to  some  extent,  the  secretion  of  bile,  is  perfectly  nat- 
ural. If,  however,  the  phrase  bilious  pneumonitis  may  ever  be 
employed  with  propriety  to  express  any  complication  of  this  kind, 
I  think  it  should  be  limited  to  those  cases  in  which,  through  some 
epidemic  influence,  the  biliary  disturbance  is  considerable,  and  the 
disease  has,  on  the  whole,  a  decided  typhoid  character.  It  some- 
times happens  that,  not  only  the  skin  and  the  urine  are  yellow 
with  bile,  and  the  matter  ejected  by  vomiting  is  bilious,  but  the 
sputa,  also,  are  deeply  tinged  with  bile, — they  forming  a  part  of 
the  bronchial  secretion.  In  such  a  case,  if  in  any,  we  may  apply 
the  phrase  bilious  pneumonitis ;  for  the  biliary  disturbance  actually 
affects  the  pulmonary  secretion.  This,  however,  is  only  a  modi- 
fication of  typhoid  pneumonitis. 

When  pneumonitis  assumes  the  typhoid  type,  some  of  the  gen- 
eral symptoms  are  decidedly  different  from  those  of  the  usual 
form  of  the  disease.  For  instance,  instead  of  a  forcible,  we  have 
a  feeble,  and,  instead  of  active  excitement  in  the  capillaries,  we 
have  diminished  action.  We  have,  also,  a  rapid  prostration  of 
strength ;  a  thickly  coated  and  sometimes  a  parched  tongue  j 
sometimes,  too,  a  delirious  or  comatose  state  of  the  mind ;  in 
short,  we  have,  to  a  greater  or  less  extent,  the  symptoms  of  typhus 
or  typhoid  fever.  In  this  case,  the  prognosis  is  very  unfavorable. 

The  treatment  of  pneumonitis  typhoides,  is,  in  some  respects, 
unlike  that  of  the  other  asthenic  forms  of  the  disease.  It  must 
be  stimulating  and  expectorant ;  but  the  ordinary  bitter  tonics 
will  not,  to  any  extent,  be  borne.  On  the  contrary,  the  treatment 
must  be  diaphoretic  and  anti-febrile.  Wine,  ammonia,  and  like 


ASTHENIC    PNEUMONITIS.  195 

stimulants  may  be  used,  in  connection  with  the  expectorant  and 
diaphoretic  powders  already  recommended  in  the  ordinary  sthenic 
pneumonitis.  Senega,  eupatorium,  &c.,  are  also  indicated.  If 
delirium  or  coma  occurs,  a  proper  regard  must  be  had  to  the  brain 
and  nervous  system.  If  the  bowels  become  constipated  or  re- 
laxed, they  must  receive  attention  accordingly.  The  condition  of 
the  kidneys,  too,  must  not  be  overlooked.  The  opportunities  to 
aid  nature,  being,  at  least,  but  limited,  no  means  within  reach 
should  be  neglected. 


SECTION   III. 
LOBULAR    PNEUMONITIS. 

This  is  sometimes  called  the  pneumonitis  of  young  children, 
for  the  simple  reason  that  they  are  specially  subject  to  it.  It  is, 
however,  not  confined  to  them,  but  is  sometimes  experienced  by 
adults. 

PATHOLOGY. — The  disease,  when  it  takes  place,  is  not  common- 
ly limited  to  one  lung,  but  extends  to  both.  Instead,  too,  of  its 
attacking  only  the  lower  portion  of  the  lungs,  it  spreads  itself 
over  a  considerable  extent.  But  it  does  not  spread  uniformly  over 
the  substance  of  the  lung  from  boundary  to  boundary.  It  attacks 
some  lobule  or  lobules  in  one  part,  and  then  passes  over  to  others 
a  little  remote,  leaving  the  intermediate  tissue  in  a  healthy  condi-' 
tion.  As  the  disease  advances,  the  portions  thus  inflamed  become 
more  and  more  numerous.  Those  that  were  left  in  health  be- 
come affected  ;  and,  at  length,  sometimes,  the  greater  part  of  the 
parenchyma  is  found  consolidated. 

In  this  form  of  pneumonitis,  the  inflammation  seems  to  com- 
mence in  the  smallest  bronchial  tubes  and  spread  to  the  vesicles 
and  the  several  tissues  of  the  affected  lobules.  Indeed,  it  is  very 
commonly  the  sequela  of  bronchitis  in  children, — the  inflamma- 
tion of  the  larger  tubes  passing  to  the  smaller,  and  thence  to  the 
parenchymatous  tissue  generally.  As  the  lobules  in  juxtaposition 
have  no  direct  bronchial  communication  with  each  other,  the  in- 
flammation has  no  direct  tendency  to  extend  to  contiguous  lob- 


196  THORACIC    DISEASES. 

nles.  By  the  course  of  the  tubes,  remote  lobules  are  just  as  in- 
timately connected  as  contiguous  ones ;  but,  after  certain  ones, 
however  scattered,  are  inflamed,  if  the  disease  continues  to  extend, 
it  must  reach  those  remaining. 

In  lobular  pneumonitis  there  is,  too,  another  peculiarity.  Some- 
times the  disease  scarcely  amounts  to  inflammation.  To  a  great 
extent,  the  lungs  are  only  passively  congested,  and  there  are  but 
slight  inflammatory  traces.  Hence,  in  children  particularly,  the 
lobules  first  and  most  affected  are  those  at  the  posterior  part  of 
the  lungs,  simply  because  the  blood,  while  the  child  is  recumbent, 
gravitates  towards  that  part.  The  color  is  a  deep  red  or  brown, 
and  sometimes  dark.  The  part  affected  is  generally  darker, 
smoother,  and  more  imperfectly  granulated  than  appears  in  ordi- 
nary hepatization ; — just  what  might  be  expected  from  the  coagu- 
lation of  the  blood  in  the  congestion  and  the  obstruction  to  the 
process  of  granulation.  Such  being  the  peculiarity  of  the  affec- 
tion, it  passes  with  difficulty  to  the  stage  of  suppuration.  The 
pleura,  too,  is  less  liable  to  become  inflamed  by  the  progress  of 
the  disease,  than  it  is  in  ordinary  pneumonitis ;  but  the  bronchi, 
being  earlier  affected  and  more  exposed  to  inflammatory  action, 
secrete  the  usual  viscid  mucus  o£  the  bronchitis  of  children. 

DIAGNOSIS. — The  constitutional  and  rational  symptoms  of  this 
disease  are,  in  general,  much  like  those  of  the  bronchitis  of  chil- 
dren. They  give  considerable  pyrexia  or  symptomatic  fever, 
generally,  a  congested  state  of  the  capillaries,  especially  those  of 
the  face  or  of  circumscribed  portions  of  its  forming  patches  on 
the  cheeks  ;  but  sometimes  paleness  and  lividity  of  countenance  ; 
an  accelerated  pulse ;  a  painful  cough  ;  and  a  good  deal  of  dysp- 
noea, manifested  by  the  distention  and  contraction  of  the  alae  nasi. 

The  physical  signs  of  lobular  pneumonitis,  so  far  as  they  can 
be  conveniently  obtained,  are  partially,  though  not  very  nearly, 
like  those  of  bronchitis,  in  its  developed  stage.  There  are  the 
sub-crepitant  and  the  mucous  rales,  formed,  in  the  largest  and  the 
medium-sized  bronchi,  by  the  existence  there  not  of  pus,  but  of 
a  mucous  secretion,  as  in  bronchitis.  The  respiration  seldom  or 
never  becomes  so  completely  of  the  shrill  bronchial  character,  as 
it  generally  is  in  the  hepatized  part  of  a  lung  in  ordinary  pneu- 


ASTHENIC    PNEUMONITIS.  197 

monitis.  As  the  disease  advances,  however,  this  character  is 
more  fully  attained,  until  it,  indeed,  becomes  quite  marked.  Per- 
cussion, at  first  clear,  becomes  gradually  duli^  until  it  approaches 
the  flatness  produced  by  ordinary  hepatization.  As  it  is  rare,  how- 
ever, for  any  considerable  portion  of  the  lung,  in  this  disease,  to 
become  perfectly  solidified,  so  the  dullness  does  not,  at  any  point, 
become  the  most  perfect.  In  estimating  the  degree  of  dullness, 
produced  by  the  disease,  in  lobular  pneumonitis.  we  labor  under 
one  disadvantage.  The  fact,  that  both  lungs  are  usually  affected 
simultaneously  forbids,  in  this  matter  of  percussion,  the  immedi- 
ate comparison  of  the  diseased  with  a  healthy  portion  of  pulmon- 
ary tissue.  By  having  in  mind,  however,  a  tolerably  correct  idea 
of  the  resonance  which  would  exist  in  health,  we  can,  with  some 
degree  of  accuracy,  judge  how  great  is  the  departure  from  the 
normal  standard.  On  the  whole,  the  disease  is  recognized  with 
an  accuracy  sufficient  for  practical  purposes.  The  only  essential 
uncertainty  respects  the  dividing  line  between  the  simple  bron- 
chitis, with  which  it  usually  begins,  and  that  bronchitis  attended 
with  inflammation  of  the  pulmonary  lobules. 

The  prognosis  in  this  disease,  if  it  is  not  complicated  with 
other  grave  diseases,  but  exists  as  a  simple  primary  affection,  is 
favorable.  The  abdominal  viscera  are  liable  to  be  affected,  giv- 
ing rise  to  indigestion,  vomiting,  diarrhoea,  or  constipation.  The 
brain,  too,  not  unfrequently  is  congested  by  an  obstruction  of  the 
circulation ;  and  the  consequence  is  delirium,  stupor,  or  coma. 
Such  cerebral  symptoms  indicate  far  more  danger  than  any  abdom- 
inal. Besides,"  they  conceal  or  very  much  modify  the  pectoral 
signs,  and,  in  some  cases,  almost  obliterate  them.  For  illustration, 
while  the  patient  is  under  the  influence  of  coma,  not  sufficient 
nervous  power  is  conveyed  to  the  bronchial  tubes  to  admit  of 
their  sensible  irritation  by  their  morbid  contents,  and,  hence,  the 
cough  ceases.  Of  course,  in  such  a  condition,  the  true  character 
of  the  malady  is  exposed  to  be  overlooked ;  and  the  liability  to 
have  the  most  appropriate  treatment  neglected,  constitutes  a  part 
of  the  patients'  danger.  But  sometimes  lobular  pneumonitis  suc- 
ceeds to  phthisis,  dysenteria,  or  other  exhausting  disease  ;  and 
then,  of  course,  the  prognosis  is  more  unfavorable. 


198  THOllACIC    DISEASES. 

TREATMENT. — This  does  not  differ  materially  from  that  of  or- 
dinary piieumouitiSj — the  doses  and  the  circumstances  of  their 
administration  being  accommodated  to  the  age  and  condition  of 
the  child.  The  expectorant  and  anti-febrile  treatment,  together 
with  a  proper  regard  to  all  the  excretions,  is  essentially  all  that  is 
requisite.  Revulsives,  however,  in  this  disease,  should  be  relied 
on  in  the  treatment  of  children,  more  even  than  in  the  treatment 
of  adults.  Hence  an  elm  and  lobelia  poultice,  or  a  paste  made 
mildly  stimulating  with  mustard,  or,  what  I  like  still  better,  an 
onion  poultice,  may  be  applied  extensively  over  the  chest.  Some 
similar  article,  too,  may  be  used  in  the  form  of  drafts  upon  the 
feet.  A  frequent  use  of  the  alkaline  wash  over  the  greater  por- 
tion of  the  body  is  serviceable ;  and  if  the  pulmonary  inflamma- 
tion produces  much  heat  externally,  a  wet.  cloth  applied  to  the 
chest  amteriorly,  laterally,  and  even  posteriorly,  will  have  a  saluta- 
ry effect. 

In  mild  cases,  however,  a  copious  secretion  from  the  bronchial 
tubes,  with  free  expectoration,  will  cure  the  disease ;  and  nature 
will  sometimes,  unaided,  effectually  employ  this  mode  of  cure. 
If,  therefore,  the  symptoms  do  not  indicate  severity,  it  may  be 
safe  to  rely  on  milder  means.  In  such  a  case,  an  occasional  dose 
of  the  compound  sirup  of  lobelia  and  sanguinaria,  the  wine  of 
ipecacuanha,  the  sirup  of  onions,  or  some  similar  expectorant  may 
be  all  that  is  essential. 


SECTION  IV. 
SECONDARY    PNEUMONITIS. 

Pneumonitis  sometimes  occurs  as  the  sequela  of  some  other 
pulmonary  disease,  particularly  of  bronchitis  and  phthisis.  In 
the  former  case,  both  diseases  consisting  in  inflammation,  the  one 
is,  in  a  sense,  absorbed  by  the  other. 

The  connection,  however,  of  phthisis  with  pneumonitis  is  very 
different.  The  two  diseases  have  an  intimate  pathological  rela- 
tion, and  cannot  be  converted  directly  the  one  into  the  other. 
But  the  existing  tubercles  unquestionably  embarrass  the  lung  in 
regard  to  resisting  the  progress  of  inflammation ;  or,  at  any  rate, 


£tJLMONARY    EMPHYSEMA.  199 

their  existence  supposes  a  low  state  of  vitality,  such  as,  if  inflam- 
mation is  once  introduced,  will  afford  no  very  effectual  resistance^ 
but  will  allow  the  pneumonitis  to  assume  the  asthenic  form. 

Besides,  if  the  inflammation  seizes  upon  the  comparatively  well 
lung  when  the  other  is  tuberculated,  or  seizes  on  the  compara- 
tively well  portion  of  the  lung,  the  other  portion  being  tubercu- 
lated, the  patient  is,  of  course,  embarrassed  in  his  power  of  respi- 
ration and  arterialization  of  the  blood,  and  is  liable  to  sink  in 
death,  as  the  immediate  consequence.  If,  however,  the  effect  is 
not  directly  fatal,  still  the  increased  prostration  given  to  the  sys- 
tem by  the  pneumonitis,  detracts  from  its  power  to  carry  on  the 
functions  of  life,  and,  of  course,  has  the  effect  to  hurry  on  the 
progress  of  the  tuberculous  disease.  Indeed,  post  mortem  exam- 
inations have  shown  that  the  lungs  of  persons  dying  of  pneumon- 
itis, complicated  with  phthisis,  exhibit  the  gray  tubercles  thickly 
disseminated  through  the  parenchyma.  This  fact  alone  is  suf- 
ficient evidence  that  the  secondary  disease  has  given  a  new  im- 
pulse to  the  primary. 

No  illustrations  of  the  symptoms  of  secondary  pneumonitis  are 
necessary ;  nor  any  special  rules  of  treatment.  What  I  have  here- 
tofore said  will  suggest  all  that  is  important. 


CHAPTER   VI. 

P  U  L  M  0  N  A  R  Y   EMPHYSEMA. 

Emphysema,  in  Greek  s^u^aa,  from  the  verb  £f/.<pu£aw,  to  in- 
flate, literally  signifies  an  inflation ;  but  applied  a  little''  less  indefi-> 
nitely,  it  signifies  a  soft  tumor  arising  from  air  admitted  into 
areolar  tissue.  In  this  sense  surgeons  still  use  it,  to  express  that 
pufliness  which  arises  from  the  admission  of  air  into  the  areolar 
tissue,  in  connection  with  the  occurrence  of  a  compound  fracture. 
In  this  case,  however,  the  most  common  source  from  which  the 
air  is  received,  is  the  lungs.  Suppose,  for  instance,  a  rib  is  frac- 
tured, and  a  bone  has  broken  through  the  .  pleura  and  wounded 
the  lung.  The  air,  passing  directly  into  the  areolar  tissue,  diffuses 
itself  over  the  chest,  neck,  and  other  parts.  It  may  even  pass 


200  THORACIC    DISEASES. 

somewhat  extensively  over  the  body.     The  parts  thus  affected 
give  a  peculiar  sense  of  crackling,  when  pressed  by  the  fingers. 

The  disease,  however,  of  which  I  am  now  to  speak  is  pul- 
monary emphysema,  or  air  in  the  parenchyma  of  ^he  lungs.  For 
brevity's  sake,  this  is  commonly  spoken  of  simply  as  emphysema, 
— the  epithet  descriptive  of  locality  being  omitted.  But  emphy- 
sema, in  this  sense,  is  divided  into  two  kinds,  vesicular  emphy- 
sema and  interlobular  emphysema.  In  the  former  kind,  the  air  is 
pent  up  in  the  vesicles,  dilated  to  a  greater  or  less  extent.  In  the 
latter,  it  is  effused  into  the  areolar  tissue,  or  held  in  its  meshes, 
between  the  lobules,  and  beneath  the  pleura. 


SECTION   I. 
VESICULAR    EMPHYSEMA. 

PATHOLOGY. — The  enlargement  of  the  cells,  in  this  case,  is  very 
analogous  to  that  dilatation  of  the  bronchial  tubes  already  de- 
scribed. In  fact,  a  slight  modification  of  the  causes  which  pro- 
duce the  one  will  evidently  produce  the  other.  In  the  normal 
state,  the  vesicles  are  of  such  a  size  as  barely  to  be  discoverable 
by  the  eye ;  but,  when  enlarged  by  emphysema,  they  very  com- 
monly attain  to  the  size  of  a  millet-seed,  and  may  become  much 
larger.  Sometimes  sacs  of  the  size  of  a  pigeon's  or  even  a  hen's 
egg  form  ;  but,  in  such  cases,  most  unquestionably  several  vesi- 
cles rupture  in  such  a  manner  as  to  form  one  cavity.  In  other 
words,  they  break  into  one. 

The  sacs  thus  formed,  by  crowding  against  one  another  and 
against  the  more  healthy  pulmonary  tissue,  are  made  to  assume 
various  shapes,  according  to  the  accidental  pressure.  If  the  sur- 
face of  a  lung  affected  with  vesicular  emphysema  be  examined, 
the  dilated  vesicles  can  be  seen  through  the  pleura.  Where  they 
are  equally  enlarged,  they  appear  like  healthy  vesicles  viewed 
through  a  magnifying  glass.  But,  sometimes  the  vesicles  of  one 
lobule  are  enlarged,  while  those  of  an  adjoining  one  are  of  the 
natural  size.  In  such  a  case,  the  emphysematous  lobule  be- 
comes conspicuous  by  its  protrusion ;  and  the  intermingling  of 
those  in  an  abnormal  and  those  in  a  healthy  condition,  render  the 


PULMONARY    EMPHYSEMA.  20 1 

surface  quite  irregular  and  uneven.  Sometimes  a  large  globular 
prominence  is  seen  resembling  a  small  bladder ;  but  this,  when 
examined,  will  be  seen  to  arise  from  a  depression  into  the  lung  of 
essentially  the  same  size  as  the  elevation  without.  Of  course,  a 
bulla  of  this  kind  cannot  be  passed  about,  as  can  the  sub-pleural 
collections  of  air  in  interlobular  emphysema. 

Under  the  pressure  of  the  finger,  an  emphysematous  portion 
of  lung  crackles,  like  a  piece  of  healthy  lung,  when  dried.  The 
walls  of  the  vesicles,  having  lost  their  elasticity,  have  become 
rigid.  The  emphysematous  portions,  also,  are  pale, — sometimes 
almost  white.  Occasionally,  the  parietes  of  the  lung  appear  as  if 
they  had  been  bleached.  This  paleness  is  most  seen  towards 
the  free  edges  of  the  lung.  "  Sometimes  these  edges  are  rounded 
and  thick ;  sometimes  thinner  and  folded  back  ;  while,  some- 
times, the  margin  is  blown  out,  as  it  were,  into  an  irregular 
fringe  ;  some  of  the  inflated  portions  remaining  connected  with  the 
lung  by  slender  pedicles,  and  these  forming  appendices  to  it,  of 
a  light  yellow  color,"  appearing  like  a  fringe  of  fat.  If  this  em- 
physematous border  be  held  between  the  eye  and  the  light,  it  will 
appear  translucent.  If  it  be  punctured,  the  surrounding  parts 
collapse,  proving  that  the  dilated  vesicles  communicate  with  each 
other. 

The  size  of  an  emphysematous  portion  of  lung  is  increased, 
and  the  tissue  becomes  specifically  lighter,  so  as  to  float  light  on 
water,  like  a  bladder  filled  with  air.  The  increased  size  causes  a 
pressure  against  the  ribs  and  the  intercostal  spaces,  and  distends 
the  walls  of  the  chest  at  the  part  corresponding  with  the  dis- 
tended portion  of  the  lung.  There  is,  consequently,  at  this  part, 
a  protuberance,  which  sometimes  becomes  very  marked.  Some- 
times, however,  so  large  a  portion  of  the  lung  is  affected,  that 
one  side  of  the  thorax  seems  generally  distended. 

The  emphysematous  portion  of  the  lung,  which  is  generally 
the  anterior  margin,  becomes  comparatively  anasmic,  while  the 
posterior  portion  is  not  so  affected,  but  sometimes  even  becomes 
congested  in  consequence  of  the  attending  dyspnoea.  In  vesicular 
emphysema,  the  morbid  condition,  once  introduced,  generally 
continues  and  gradually  becomes  worse.  The  interference  with 
•the  nutrition  of  the  lung  renders  it  less  able  to  resist  the  cause  of 
26 


202  THORACIC    DISEASES. 

• 

the  affection  ;  and,  hence,  the  disease  is  almost  necessarily 
progressive. 

Vesicular  emphysema  is  very  liable  to  be  complicated  with 
other  diseases.  In  the  first  place,  it  is  probable  that  bronchitis, 
either  acute  or  chronic,  is  usually  the  leading  cause  of  its  exis- 
tence. The  inflammation  of  the  acute  form,  or  the  thickening 
of  the  membrane  in  the  chronic,  it  is  easy  to  conceive,  may  so 
affect  the  entrances  into  the  vesicles  that,  while  the  air  is  readily 
forced  in,  in  inspiration,  it  does  not  as  readily  return  in  expiration  ; 
and,  hence,  the  liability  of  the  vesicles  to  become  permanently 
enlarged.  The  air  being  incarcerated  and  accumulating  in  the 
vesicles,  they  yield  to  its  distending  force  and  lose  their  elasticity. 
If,  at  the  same  time,  there  exists  a  hard  cough,  the  forcible  efforts 
made  will  increase  the  difficulty. 

But,  besides  this  connection  of  vesicular  emphysema  with 
bronchitis,  the  former  disease  is  liable  to  induce  the  latter,  and 
thus  stand  to  it,  in  the  relation  of  cause,  as  well  as  effect.  The 
embarrassment  of  the  respiration  and  the  agitation  produced  ne- 
cessarily determine  more  blood  to  the  neighboring  tubes,  produ- 
cing congestion  and  the  liability  to  inflammation  or  bronchitis. 
The  congested  or  posterior  portions  of  the  pulmonary  tissue,  too3 
readily  pass  into  a  state  of  inflammation,  constituting  pneumon- 
itis.  Again,  the  obstruction  of  the  blood  in  passing  through  the 
lungs  prevents  the  right  side  of  the  heart  from  emptying  itself 
freely.  The  consequence  is  palpitation,  or  increased  muscular 
contractions  of  the  right  ventricle,  followed  by  a  "  yielding  of  its 
walls  to  the  augmenting  [pressure  of  the  contained  blood."  Of 
course,  this  embarrassment  in  the  circulation  is  greatest  when  the 
dyspnoea  is  greatest ;  but  the  right  cavities  of  the  heart  become 
permanently  dilated,  and  the  dilatation  leads  to  anasarca,  particu- 
larly oedema  of  the  feet  arid  ankles.  Finally,  the  opinion  has 
prevailed,  that  asthma  is  induced  by  this  disease  ;  and  it  is  easy  to 
see  how  the  nervous  system  may  become  so  affected  by  it  as  to 
constrict  the  bronchial  tubes.  The  manifestations  of  emphysema, 
however,  so  far  resemble  those  of  asthma,  that  the  one  disease 
has  evidently  been  often  mistaken  for  the  other. 

Having  referred  to  one — perhaps  the  principal — cause  of  em- 
physema, I  now  add  further,  that,  besides  bronchitis,  any  thing 


PULMONARY    EMPHYSEMA.  203 

else  which  impedes  the  free  exit  of  air  from  the  lungs  may  pro- 
duce it ;  and,  among  the  other  causes,  may  be  reckoned  blowing 
on  wind  instruments,  and  pressure  made  on  parts  of  the  lung,  as 
by  a  tumor  in  the  thorax,  an  enlarged  heart,  an  aneurism,  tight 
lacing,  or  a  deformed  condition  of  the  chest. 

DIAGNOSIS. — Among  the  general  signs  of  vesicular  emphysema, 
an  habitual  shortness  of  breath,  with  occasional  paroxysms  of 
extreme  dyspnosa,  is  prominent.  In  a  case  of  moderate  severity, 
the  patient  is  conscious  of  a  little  shortness  of  breath,  on  walking 
up  a  hill  or  making  some  unusual  exertion.  In  an  extreme  case, 
the  act  of  ascending  a  few  steps  of  a  staircase  will  render  him 
breathless.  The  paroxysms  of  dyspnoea  will  frequently  occur 
without  any  assignable  cause,  and,  when  existing,  will  oblige 
the  patient  to  sit  erect  or  lean  forwards.  In  such  a  case,  the 
muscles  of  respiration  are  thrown  into  violent  action  ;  the  face 
becomes  livid  and  swollen,  and  great  constriction  is  experienced 
at  the  pracordia. 

There  is,  also,  in  this  disease,  a  cough  which  is  somewhat  pe- 
culiar. At  first,  it  is  rather  dry  and  wheezing  ;  or  there  is,  to  a 
small  extent,  an  expectoration  of  thick  pearly  sputa,  but,  after 
paroxysms  of  dyspnoea  are  established,  there  is  a  more  copious 
ejection  of  a  thin,  glairy,  and  transparent  matter.  Palpitation  of 
the  heart,  and  that  secondary  consequence,  oedema  of  the 
ankles,  are  also  among  the  general  signs  of  this  disease. 

The  physical  signs  in  a  well  developed  case  of  vesicular  em- 
physema are  distinctly  marked.  They  are  principally  these, — 
the  distention  of  a  portion  of  the  thorax,  diminished  movements 
of  its  walls,  resonance  on  percussion,  a  peculiar  feebleness  of  the 
healthy  sounds  of  respiration,  and  the  cmphysernatous  crackling. 
The  last,  when  heard,  is  pathognomonic  of  the  one  or  the  other 
form  of  emphysema. 

The  distention  of  the  thorax  is  necessarily  the  greatest  in  those 
portions  in  which  the  dilatation  of  the  vesicles  is  the  greatest,  and 
those,  I  have  already  said,  are  at  the  anterior  margin  of  the  lungs. 
Hence  the  anterior  thoracic  plane  becomes  decidedly  convex. 
The  form  of  the  distended  portion  is  generally  rather  oval,  hav- 
ing its  long  diameter  parallel  with  the  axis  of  the  body.  It  is, 


204  THORACIC    DISEASES. 

however,  irregularly  prominent  and  unsymmetrical,  bulging  here 
and  there  in  correspondence  with  the  enlargement  within.  If 
the  emphysema  becomes  extensive  on  one  side,  and  especially  if 
on  both,  it  elevates  the  ribs  and  gives  to  the  whole  chest  a  form 
nearly  cylindrical.  But  this  happens  only  to  those  who  have  long 
been  subject  to  the  disease.  The  intercostal  spaces,  in  this  dis- 
ease, are  elevated  more  than  to  retain  their  ordinary  relation  to 
the  ribs.  The  intercostal  tissues,  being  flexible,  are  pressed  up  to 
a  level  or  more  with  the  ribs.  The  appearance  of  the  clavicle  is 
almost  effaced,  the  spaces  above  and  below  are  so  raised.  It  is 
proper  here  to  remark,  that  the  distention  of  the  chest  in  emphy- 
sema is  always  comparatively  moderate,  and  never  attains  to  that 
degree  which  is  common  in  pneumothorax. 

The  movement  of  the  thorax  in  vesicular  emphysema,  is  decid- 
edly less  than  in  health.  The  lung  having  lost  its  elasticity,  and 
the  vesicles  during  respiration,  remaining  distended  with  air,  the 
thorax  necessarily  preserves  nearly  the  position  which  it  has  im- 
mediately after  inspiration.  Its  motion  is  very  limited.  This, 
however,  gives  rise,  to  some  extent,  to  that  peculiar  motion  of  the 
abdominal  viscera  usually  termed  abdominal  breathing. 

The  resonance  on  percussion  is  greater,  in  vesicular  emphyse- 
ma, than  in  health,  from  the  fact,  that  the  lung  contains  more  air, 
and  is  permanently  distended.  With  persons  whose  thoracic  par- 
ietes  are  thin,  the  abnormal  resonance  is  considerable  ;  but,  with 
corpulent  persons,  and  especially  with  those  whose  advanced  age 
has  appreciably  diminished  the  elasticity  of  the  chest,  a  moderate 
degree  of  emphysema  will  not  give  much  unusual  clearness. 
Over  the  most  dilated  portion  of  the  lung,  the  clearness  is  always 
the  greatest.  Occasionally,  where  the  lung  is  extensively  dilated, 
the  resonance  approaches,  in  degree,  that  produced  by  pneumotho- 
rax ;  but  the  sound,  in  the  former  case,  is  never  so  tympanitic  as 
in  the  latter. 

In  regard  to  the  sounds  of  respiration,  both  the  healthy  bron- 
chial and  the  vesicular  sound  are  diminished.  Before  the  disease, 
however,  has  made  much  progress,  and  has  not  very  much  com- 
pressed the  lung,  the  bronchial  sound  remains  nearly  normal ;  but, 
in  that  portion  to  which  the  disease  has  extended,  the  vesicular 
sound  is  completely  destroyed.  The  vesicles,  when  once  filled, 


PULMONARY  EMPHYSEMA.  205 

remaining   inflated,    of  course,  can  give    none  of  the  ordinary 
sounds. 

But  the  pathognomonic  sign  of  emphysema,  in  one  of  its  forms, 
when  heard,  is  the  emphysematous  crackling  sound.  This  is  a 
rustling  sound,  which  nothing  but  the  condition  of  the  lung  ex- 
isting in  this  disease  can  produce.  It  is  never  heard  till  the  dis- 
ease becomes  severe.  Indeed,  it  is  probable,  that  vesicular  emphy- 
sema, uncombined  with  interlobular,  never  gives  rise  to  it,  till  nu- 
merous sacs  are  formed  from  the  breaking  of  one  cell  into  another. 
Be  that  as  it  may,  the  sound  supposes  a  dry,  hardened,  and  not 
very  pliant  condition  of  the  membranes.  It  may  even  be,  that 
it  involves  some  inflammation  of  the  parts  affected. 

PROGNOSIS. — The  prognosis,  in  simple  vesicular  emphysema,  is 
favorable,  so  far  as  prolonged  life  is  concerned.  Persons  seldom  or 
never  die  of  this  disease,  alone.  Recovery,  however,  is  hardly  to 
be  expected ;  and  the  danger  lies  in  a  complication  with  other  and 
graver  affections.  Generally,  the  progress  of  the  disease  is  slow 
and  undisturbed.  If,  however,  it  happens  to  be  suddenly  devel- 
oped, by  the  influence  of  some  preceding  acute  disorder,  there 
may  be  a  partial,  though  there  is  seldom  or  never,  a  full  return 
towards  health. 

TREATMENT. — But  little  treatment  of  vesicular  emphysema  is  of 
any  service.  Sinapisms,  applied  between  the  shoulders  posteriorly, 
and  over  the  dorsal  vertebrae  may,  by  their  stimulating  power,  af- 
ford some  relief  in  a  paroxysm  of  dyspnoea.  The  anti-spasmodic 
effect  of  the  lobelia  inflata,  too,  is  favorable.  It  may  be  given  in 
common  tincture,  in  doses  of  twenty  or  thirty  drops.  I  prefer^ 
however,  to  combine  it  with  cypripedium  pubescens  or  scutellaria 
lateriflora.  The  compound  wine  tincture,  according  to  the  formu- 
la, may  be  given  in  dram  doses,  every  two  hours.  To  this  prep- 
aration, twenty  or  thirty  drops  of  chloric  ether  may  be  added, 
with  a  favorable  anti-spasmodic  effect.  Opiates  combined  with 
nauseants,  in  sufficient  doses  to  quiet  the  cough,  have  been  rec- 
ommended ;  but  the  effect  of  the  simple  nervines,  in  connection 
with  the  nauseants,  is  far  preferable. 

The  moderation  of  the  paroxysms  is  essentially  all  that  should 


206 


THORACIC    DISEASES. 


be  aimed  at.  We  know  of  no  means  of  eradicating  the  disease. 
Of  course,  if  it  is  complicated  with  other  difficulties  which  are 
remediable,  those  should  be  removed ;  and  circumstances  tending 
to  aggravate  it  may  be  guarded  against. 

SECTION  II. 

INTERLOBULAR    EMPHYSEMA. 

PATHOLOGY. — The  areolar  tissue  which  binds  the  lobules  to  one 
another,  is,  in  its  normal  state,  quite  dense  and  close ;  but,  when 
inflated  with  air,  it  is  capable  of  a  good  deal  of  expansion.  It  is, 
in  this  tissue,  that  the  air  is  found  in  interlobular  emphysema. 
When  the  disease  is  slight,  such  of  the  affected  parts  as  are  visi- 
ble on  the  surface  of  the  lung,  appear  as  little  bubbles  of  air,  ar- 
ranged like  beads  upon  a  thread.  In  extreme  cases,  however,  the 
lobules  are  widely  separated  by  the  effused  air, — the  partitions 
being  sometimes,  even  one  inch  in  breadth.  These  partitions  are 
broadest  towards  the  surface  of  the  lung,  and  narrowest  in  the 
deepest-seated  portions.  Indeed,  they  show  an  arrangement  some- 
what like  the  section  of  an  orange  in  which  the  septa  radiate  and 
diverge  from  a  centre. 

In  this  form  of  emphysema,  it  is  common  for  bullas  to  form  on 
the  surface  of  the  lung,  by  means  of  air  in  the  subserous  areolar 
tissue, — that  is,  the  tissue  which  connects  the  pleura  with  the 
pulmonary  parenchyma.  These  bullee  maybe  distinguished  from 
the  bladder-like  prominences  which  appear  there  in  vesicular  em- 
physema, and  which  are  dilated  vesicles.  The  former  are  moved 
hither  and  thither,  underpressure  ;  the  latter  are  stationary.  This 
sub-pleural  effusion  of  air  is  sometimes  very  great.  The  bulte 
are  said,  sometimes,  to  equal  a  hen's  egg  in  size,  or  even  to  be 
larger.  "  Bouillaud,"  says  Dr.  Watson,  "  mentions  a  case  in  which 
the  bladder  or  pouch  was  equal  to  the  size  of  a  stomach  of  ordin- 
ary dimensions." 

The  contents  of  these  sacs  are  supplied  from  the  air  passages, 
doubtless  by  the  rupture  of  some  of  the  superficial  vesicles.  Sup- 
pose then,  such  sub-pleural  collections  of  air,  and  suppose  that, 
under  the  pressure,  the  pleura  gives  way.  The  immediate  conse- 


PULMONARY    EMPHYSEMA.  207 

quence  is  pneumo-thorax,  complicating  the  emphysema ;  and  this 
condition  of  things  sometimes,  though  not  often,  occurs. 

In  severe  cases  of  interlobular  emphysema,  the  air  readily  passes 
to  the  areolar  tissue  of  the  mediastinum,  and  thence  to  the  sub- 
cutaneous areolar  tissue  of  the  neck  and  chest.  In  such  a  case, 
we  have  not  merely  pulmonary  emphysema,  but  emphysema,  in  a 
more  enlarged  sense. 

Between  vesicular  emphysema,  and  interlobular,  there  is  an  im- 
portant difference  in  the  circumstances  of  their  formation.  The 
former  is  slowly  and  gradually  established  ;  the  latter,  suddenly. 
The  permanent  dilatation  of  the  vesicles  requires  time  ;  and  they 
lose  their  elasticity  and  break  into  one  another  only  by  degrees. 
The  interlobular  effusion  of  air,  on  the  contrary,  may  be  effected 
in  a  few  minutes,  or  even  seconds.  It  is  produced  by  some  vio- 
lence. A  woman  may  so  exert  herself  in  childbirth,  or  a  man  in 
lifting  some  heavy  body,  that,  as  a  deep  inspiration  is  taken  and 
the  glottis  is  voluntarily  closed,  some  rupture  takes  place,  opening 
a  vesicle  or  vesicles  into  the  areolar  tissue. 

DIAGNOSIS. — -The  general  and  the  physical  signs  of  this  form  of 
emphysema  are  mostly  the  same  as  those  of  the  vesicular.  The 
emphysematous  crackling,  however,  is  much  more  extensive  and 
perfect,  in  this  form  than  in  the  other.  The  dyspnoea,  too,  the 
distention  of  a  portion  of  the  chest,  and  the  resonance  on  the  per- 
cussion of  that  portion  may  be  greater.  But  the  suddenness  with 
which  interlobular  emphysema  is  developed,  and  the  graver  char- 
acter which  it  assumes,  afford  the  principal  means  of  discriminat- 
ing it. 

PROGNOSIS. — The  prognosis  in  this  case  is  very  different  from 
that  in  the  other.  Under  favorable  circumstances,  the  newly  de- 
veloped disease  will  sometimes  cure  itself.  The  rupture,  proba- 
bly under  the  influence  of  inflammation  and  the  subsequent  gran- 
ulating process,  closes  over,  and  the  effused  air  is  absorbed.  If, 
however,  this  does  not  soon  take  place,  or  if  the  opening  is  re- 
established and  remains,  the  disease  is  generally,  soon  fatal. 

TREATMENT. — But  little  can  be  done  directly  to  aid  the  process 


208  THORACIC    DISEASES. 

of  cure,  if  it  takes  place.  Equalizing  the  circulation  and  quiet* 
ing  the  nervous  system,  so  as  to  allow  the  reparative  process  to 
go  on  uninterrupted,  will  be  of  service.  If  the  disease  is  termin- 
ating fatally,  the  means  of  palliating  it,  or  relieving  the  urgent 
symptoms,  are  the  same  as  recommended  for  vesicular  emphy- 
sema. 


CHAPTER  VII. 

PULMONARY    CONGESTION. 
PATHOLOGY. — This  is  an  abnormal  fullness  of  the  blood-vessels 

% 

of  the  lungs,  which  are  situated  anatomically  between  the  right 
and  the  left  side  of  the  heart.  It  is  produced,  sometimes  by  gen- 
eral and  sometimes  by  local  causes.  When  the  right  ventricle  of 
the  heart  throws  more  blood  into  the  lungs,  than  the  left  ventri- 
cle throws  over  the  system,  that  is,  away  from  the  lungs,  there 
must  necessarily  be  an  accumulation,  and  we  speak  of  the  lungs 
as  congested.  This  difficulty  arises  from  various  causes.  Cough- 
ing in  pertussis  or  in  severe  bronchitis,  may  arrest,  for  a  time,  the 
circulation  in  the  lungs.  Running,  straining,  or  any  violent 
execution,  by  which  the  person  is  put  out  of  breath  may  do 
the  same. 

But  disordered  nervous  action  will  frequently  produce  a  less 
temporary  congestion  of  the  lungs.  This  remark  is  applicable  to 
both  sexes,  though  it  is  mainly  illustrated  in  the  case  of  nervous 
and  hysterical  females.  Taking  cold  at  the  menstrual  period, 
habitual  amenorrhoea,  or  almost  any  disturbance  of  uterine  action, 
with  some  constitutions,  will  be  sufficient  to  develop  pulmonary 
congestion. 

There  are  two  very  different  conditions  under  which  this  con- 
gestion occurs.  One  is  with  females  who  are  of  sanguine  tem- 
perament and  plethoric  habit,  with  whom  the  congestion  is  of  the 
active  kind.  The  other  is  with  those  whose  tendency  is  towards 
anaemia  or  chlorosis. — whose  blood  lacks  corpuscles,  or  corpuscles 
and  fibrine,  and  with  whom  the  congestion,  when  it  occurs,  is  of 
the  passive  kind. 


PULMONARY    CONGESTION.  209 

DIAGNOSIS. — The  indications  of  this  disease  are,  principally, 
'•dyspnosa  or  hurried  respiration,  the  lungs  but  imperfectly  filling 
with  air  at  each  inspiration :  some  degree  of  dullness  on  percus- 
sion, in  consequence  of  the  fullness  of  the  congested  lungs ;  and 
the  existence  of  haemoptysis  or  pulmonary  hemorrhage. 

This  last  symptom,  when  connected  with  active  congestion, 
may  be  called  tonic  hemorrhage ;  but,  when  with  passive  con- 
gestion, atonic  hemorrhage.  Hemorrhage  not  imfrequently  occurs 
in  connection  with  the  existence  of  phthisis,  either  at  an  early 
period,  or  more  often  at  an  advanced.  But,  in  all  these  cases,  it 
is  to  be  regarded  as  a  symptom  of  disease,  rather  than  as  disease 
itself.  In  phthisis,  blood-vessels  are  invaded  by  the  tubercular 
disease,  and  even  laid  open.  In  congestion,  the  case  is  very  dif- 
ferent. Sometimes,  the  smaller  blood-vessels,  it  is  true,  are  rup- 
tured. This  is  evidently  done  when  the  hemorrhage  suddenly 
follows  a  straining  or  violent  effort ;  but,  ordinarily,  the  discharge 
of  blood  is  an  effusion  from  the  mucous  membrane  of  the  bron- 
chial tubes.  Whether  the  leakage  be  from  the  capillaries,  or,  as 
is  more  probable,  from  the  smallest  veins,  it  is  from  vessels  lying 
near  the  mucous  surface  of  the  tubes,  they  being  there  congested. 
In  active  congestion,  the  blood  is  too  violently  forced  into  those 
vessels.  In  passive  congestion,  the  vitalizing  power  of  the 
blood  itself  is  feeble,  the  coats  of  the  vessels  most  often,  are 
morbidly  relaxed,  and  the  mechanical  pressure  of  the  current 
within  produces  an  effusion,  while  there  is  not  sufficient  power  to 
force  the  blood  in  its  proper  channels.  The  existence  of  the 
blood  in  the  larger  and  the  medium-sized  bronchi,  before  it  is  ex- 
pectorated, causes  the  mucous  and  the  sub-crepitant  rales  ;  but 
thinness  of  the  liquid  through  which  the  air  passes,  renders  the 
sound  sharper  and  more  snapping  than  is  that  of  those  rales  when 
made  in  mucus  or  pus. 

TREATMENT. — If  hemorrhage  has  occurred,  the  arrest  of  that  is 
the  first  indication  to  be  fulfilled.  To  effect  that  object,  the  in- 
ternal use  of  astringents,  or  astringents  combined  with  vegetable 
stimulants,  is  valuable.  As  astringents,  cutechu,  kino,  tannin, 
trillium  pendulum,  and  lycopus  virginicus  are  all  valuable.  The 
last,  most  of  all,  has  a  special  reputation  as  an  astringent  and  a 
27 


210  THORACIC    DISEASES, 

styptic.  Whatever  article  is  relied  on,  liberal  doses  should  be 
given  and  repeated  every  few  minutes,  till  the  hemorrhage  ceases. 
The  addition,  in  small  quantity,  of  some  simple  vegetable  stimu- 
lant, as  capsicum  baccatum,  to  the  astringent,  increases  its  effi- 
cacy. The  best  known  styptic,  however,  to  be  employed,  -whether 
in  haemoptysis,  or  in  other  hemorrhages,  is  the  chloride  of  sodium 
(common  salt.)  A  saturated  solution  of  this  in  water  should  be 
prepared ;  and  the  patient  may  drink  from  a  fluid  dram  to  a  fluid 
ounce  of  the  liquid,  frequently  repeating  the  dose,  till  relief  is 
gained.  The  modus  operandi  of  this  remedy  is  not  very  fully 
understood.  I  suppose,  however,  it  acts  by  means  of  the  stimu- 
lating or  energizing  properties  introduced  into  the  blood  by 
venous  absorption.  In  connection  with  these  means,  soaking  the 
feet  in  warm  water,  swallowing  small  pieces  of  ice,  and  other 
means  of  equalizing  the  circulation  are  useful.  The  blood  should, 
as  much  as  possible,  be  invited  and  impelled  away  from  the  part 
affected. 

In  regard  to  the  removal  of  the  congestion  itself,  and  guarding 
against  future  hemorrhages,  different  means  are  required,  accord- 
ing to  the  existing  conditions  and  causes.  If  the  hemorrhage  is 
the  result  of  violence, — especially,  if  some  of  the  vessels  have 
been  ruptured,  rest  or  the  most  quiet  condition  possible  should  be 
peremptorily  enjoined.  The  nervous  system  should  be  kept  quite 
calm  ;  and,  if  possible,  all  severity  of  coughing  should  be  avoided. 
Should  pulmonary  pneumonitis  occur,  it  must  be  treated  accord- 
ingly. After  this  has  subsided,  if  a  weakness  at  the  spot  remains, 
gentle  local  stimulants,  as  strengthening  plasters,  may  be  of  some 
service.  But  regard  to  the  general  health,  in  the  use  of  simple 
restoratives,  should  give  the  leading  feature  to  the  treatment. 

In  the  case  of  a  sanguine  and  plethoric  female,  especially  if  there 
is  menstrual  suppression  or  a  partial  interruption  of  the  menstrual 
function,  the  emmenagogue  and  depletive  treatment  is,  to  an  ex- 
tent, indicated.  Hence,  agents  to  produce  uterine  action  and  a 
hydragogue  cathartic  effect,  such  as  macrotine,  podophilline,  and 
the  like,  are  beneficial. 

But,  in  the  case  of  passive  congestion,  giving  rise  to  atonic 
hemorrhage,  a  very  different  treatment  must  be  adopted.  The 
chlorotic  or  anaemic  condition  of  the  blood  requires  primary  at- 


PULMONARY  APOPLEXY.  211 

tention.  The  deficient  corpuscles  and  fibrine  must  be  restored, 
and  thus  more  vitality  be  added  to  the  system.  Direct  and  ef- 
fective emmenagogues  used  in  this  case,  produce  only  evil. 
Agents  adapted  to  produce  a  healthy  uterine  action,  as  the  trillium 
pendulum,  rnacrotine,  and  the  like,  will  do  no  injury,  but  will  be 
favoraqle  ;  but.  all  depleting  measures  must  be  avoided.  Stimu- 
lating drafts  applied  to  the  feet,  the  tepid  sitz  bath  occasionally, 
and  friction  to  the  surface,  are  beneficial.  The  vegetable  stimu- 
lants and  bitter  tonics,  to  some  extent,  are  indicated ;  but  the 
most  effective  means  of  removing  the  disease  are  the  use  of  iron, 
in  some  form-,  and  such  vegetable  agents  as  directly  improve  the 
vital  powers  of  the  blood.  Of  the  different  preparations  of  iron, 
the  iodide,  the  carbonate,  and  the  sulphate  are  all  valuable  ;  but  I 
prefer  the  last.  Of  the  vegetable  remedies  indicated,  the  com- 
pound sirup  of  aralia  nudicaulis  and  guaiacum  wood  are  among 
the  most  efficacious. 


CHAPTER   VIII. 

PULMONARY    APOPLEXY. 

I  use  this  term  for  want  of  a  better,  though  there  is  an  etymo- 
logical objection  to  its  use.  Apoplexy,  in  Greek  cwrwX"/^!^  is  from 
the  preposition  a™  from  and  the  verb  tfX-^w  to  strike, — to  strike 
from,  or  strike  down.  The  term  is  applied  to  a  disease  of  the 
brain,  under  which  a  person  falls  suddenly  down  and  lies  in  a 
comatose  condition,  the  circulation  and  the  respiration  continuing, 
but  the  breathing  being  commonly  stertorous.  This  disease, 
pathologically  examined,  was  found  to  consist  of  a  congestion  of 
the  blood  vessels  and  an  extravasation  of  blood  upon  the  brain. 

When,  therefore,  it  was  found  that  a  certain  pathological 
condition  of  the  lungs  consists  in  the  extravasation  or  the  effusion 
of  blood  into  the  areolar  tissue  or  the  parenchyma,  and  that  the 
blood  remains  fixed  there,  as  does  that  thrown  out  upon  the 
brain  in  the  cranium,  the  term  apoplexy  was,  by  an  analogy  not 
very  remote,  applied  to  that  pathological  condition,  and  it  was 
called  pulmonary  apoplexy. 


212  THORACIC    DISEASES. 

PATHOLOGY. — In  this  disease,  there  must  necessarily  be,  at  the 
outset,  congestion  of  the  blood-vessels,  to  a  greater  or  less  extent ; 
but  the  hemorrhage  which  occurs  is  peculiar  and  characteristic. 
The  blood,  instead  of  passing  into  the  bronchial  tubes  and  being 
discharged  by  coughing,  is  lodged  in  the  areolar  tissue,  and  con- 
fined there,  or  is  effused  into  the  vesicles  and  the  terminal  bron- 
chial tubes  which  are  situated  within  the  lobules.  Sometimes 
the  blood  is  evidently  extravasated,  and  the  pulmonary  tissue  is 
broken  down  or  torn.  In  this  disease,  there  is  a  clear  resem- 
blance between  the  injury  and  that  which  exists  in  the  brain 
when  there  is  cerebral  hemorrhage.  Ordinarily,  however,  there  is 
no  such  laceration  ;  but  the  lobules  are  gorged  with  blood  which 
has  been  somehow  effused.  Pathologists  are  not  agreed  to  what 
extent  the  blood  passes  directly  from  the  coats  of  the  vessels  into 
the  areolar  tissue,  and  to  what  extent  it  is  poured  into  the  air 
passages,  at  or  near  their  terminations.  Sometimes,  with  the 
induction  of  this  disease,  there  is  no  hemoptysis,  though  oftener 
there  is,  at  least,  some  slight  discharge  of  blood,  in  connection 
with  coughing. 

Now,  if  the  blood  is  pent  up  in  the  areolar  tissue,  it  of  course 
cannot  escape.  The  fact,  that  there  is  generally  some  haemopty- 
sis, proves  that  some  blood  does  actually  enter  the  air  passages. 
If  the  blood  mainly,  or  to  any  extent,  is  deposited  in  the  air  pas- 
sages, why  is  it  not  thrown  out  by  the  cough  which  the  irritation 
must  produce  ?  To  this  it  is  replied,  that,  in  the  compressed  lobules, 
the  nervous  energy  may  be  so  deadened,  by  the  pressure  or  other 
means,  that  no  important  degree  of  irritation  is  produced ;  or  the 
bronchial  outlet  from  each  lobule  may  become  compressed  or 
blocked  up  with  coagulated  blood  so  as  not  to  allow  of  an  evacua- 
tion. 

This  disease,  like  the  congestion  already  considered,  has  been 
very  commonly  referred  to  the  effect  of  a  contracted  mitral  orifice 
— not  allowing  the  blood  to  return,  from  the  lungs,  with  sufficient 
rapidity.  But,  though  this  will  account  for  the  congestion  of  the 
pulmonary  apoplexy,  except  the  ordinary  pulmonary  hemorrhage 
and  hasmoptysis,  yet  if  the  blood  is  effused  directly  into  the  areolar 
tissue,  the  cause  must  be  sought  in  the  pulmonary  parenchyma, 
and  not  in  the  heart ;  and,  if  the  effusion  is  direct  into  the  term- 


PULMONARY  APOPLEXY.  213 

inal  air  passages,  and  yet  there  is  little  or  no  tendency  to 
hasmoptysis,  the  cause  of  that  peculiarity  must  be  sought  for  in 
the  lungs  themselves.  Some  consider  that  the  disease  is  con- 
nected with  the  capillaries  rather  than  with  the  larger  blood- 
vessels, and  that  it  differs  from  inflammation  mainly  in  the  blood's 
lacking  the  phlogistic  and  reactive  character  of  inflammation. 
It  appears  that  there  is  a  weakness  in  the  vessels  and  the  tissues 
concerned,  by  which  the  blood  leaks  or  oozes  into  its  place  of 
deposit,  and  little  or  no  vital  reaction  is  established. 

Dr.  Thomas  Watson  thinks  there  is  sufficient  reason  for  con- 
sidering the  blood  in  pulmonary  apoplexy  to  have  been  first 
poured  into  one  or  more  of  the  larger  branches  of  the  bronchial 
tubes,  and  then  to  be  driven  backward  into  the  pulmonary  lobules 
by  the  convulsive  efforts  which  the  patient  makes  in  respiring,  or 
by  paroxysms  of  coughing.  He  thinks  that  clots  of  blood  found 
to  exist  in  different  and  distinct  parts  of  the  lung,  at  the  same 
time,  are  phenomena  to  be  explained  in  this  manner.  When  the 
texture  in  some  of  the  lobules  is  lacerated,  he  thinks  that  the 
lesion  happens  through  the  violence  of  regurgitation  on  the  part 
of  the  blood  in  the  bronchi.  In  support  of  this  view,  he  relies 
mainly  on  the  fact  that  the  body  of  a  person  who  died  of  a  rup- 
ture of  the  lingual  branch  of  the  carotid  artery,  while  suffering 
from  tonsillitis,  exhibited,  at  the  post  mortem  examination,  hard, 
dark  and  small  masses  of  blood,  scattered  through  the  parenchyma 
of  the  lungs,  as  well  as  clots  about  the  trachea  and  glottis. 
The  doctor  takes  it  for  granted  that  the  blood  forming  these 
masses  in  the  parenchyma  passed  there,  from  the  lingual  artery 
through  the  trachea  and  bronchi,  and  hence  concludes,  that  all 
such  masses  are  formed  from  blood  received  through  the  bronchi 
leading  to  the  places  of  their  existence.  According  to  this  theory, 
it  might  be  inquired,  how  the  engorged  condition  of  the  lung 
should  take  place,  and  yet  no  hemoptysis  whatever  occur,  as 
sometimes  happens ;  but  the  subject  is  one  on  which,  it  seems  to 
me,  we  need  more  light. 

When  the  lung  in  the  condition  of  pulmonary  apoplexy  is  ex- 
amined, there  are  generally  found  hard  knots  or  compact  masses, 
situated  here  and  there,  mainly  in  the  lower  lobe  and  towards  its 
posterior  surface.  These  knots  are  of  a  dark  red  or  brown  color, 


214  THORACIC    DISEASES. 

and  are  of  different  sizes,  ranging  from  the  size  of  a  pea  or  small 
marble  to  that  of  a  hen's  egg.  When  cat  through,  they  show  a 
circumscribed  surface,  in  strong  contrast  with  the  surrounding 
tissue.  They  are  evidently  composed  mainly  of  deposited  and 
coagulated  blood.  As  the  different  lobules  have  no  direct  com- 
munication with  each  other  when  the  masses  become  large,  they 
are  evidently  formed  by  the  engorgement  of  several  lobules  in 
proximity. 

Sometimes  there  are  but  few  small  masses  or  nuclei.  The  dis- 
ease consists  mainly  in  the  existence  of  one  large  diffused  mass, 
occupying  nearly  the  whole  of  one  tube,  but  having  limits  ob- 
scurely defined, — the  color  gradually  deepening  in  the  course 
from  the  border  to  the  centre.  In  this  case,  the  central  portion  is' 
obviously  formed  almost  solely  of  a  black  clot  of  blood  ;  while, 
at  a  distance  from  the  centre,  the  sanguineous  deposit  is  more 
diffused  and  intermingled  with  the  pulmonary  tissue. 

DIAGNOSIS. — The  symptoms  of  pulmonary  apoplexy  are  not  con- 
stant. Among  those  which  more  generally  appear,  are  dyspnoea, 
a  sense  of  tightness  or  a  dull  pain  in  the  chest,  a  cough,  and  he- 
moptysis. The  blood  expectorated  may  be  a  mere  tinging  of  the 
sputa,  or  a  little  pure  blood  raised  in  coughing.  Often,  however, 
in  this  disease,  there  is  little,  sometimes  no  haemoptysis,  the  ef- 
fused blood  coagulating  and  remaining  undisturbed  in  its  place  of 
deposit. 

Among  the  physical  signs  is  feebleness  or  absence  of  the  vesic- 
ular sound  over  the  part  affected.  If  the  disease  is  extensive, 
the  sound  will  be  almost  entirely  wanting  in  the  lung.  At  the 
same  time,  the  respiration  may  partake  decidedly  of  the  shrill 
bronchial  character,  especially  towards  the  root  of  the  lungs.  In 
one  remarkable  case  which  came  under  my  treatment,  the  air- 
passages  of  the  right  lung  were  so  completely  blocked  up,  that  no 
sound  of  respiration  whatever  was  heard,  except  over  the  largest 
bronchi,  and  the  superior  lobe.  Of  course,  what  sound  there  was, 
was  of  the  shrill  bronchial  character.  When  sufficient  hemorrhage 
takes  place,  or  blood  is  found  in  sufficient  quantity  in  the 
medium-sized  bronchi,  the  sub-crepitant  rale  is  heard ;  arid,  in  the 
largest  bronchi  the  mucous  is  also  heard,  if  there  is  sufficient 


PULMONARY  APOPLEXY.  215 

liquid  there  to  produce  it.     These  rales,  of  course,  have  the  pecu- 
liar character  given  them  by  the  thinness  of  the  liquid. 

If  the  disease  is  slight,  there  will  be,  on  percussion,  a  slight 
dullness  only  ;  but,  in  graver  cases,  the  dullness  will  be  consider- 
able. In  the  unusual  case  to  which  I  have  just  alluded,  there 
was  dullness  amounting  almost  to  flatness,  all  over  the  lower  half 
or  more  of  the  lung,  anteriorly,  posteriorly,  and  laterally.  Indeed, 
the  percussion  was  hardly  normal  on  any  portion  of  the  right  side 
of  the  thorax.  This  case  commenced  suddenly  in  the  night,  after 
exposing  the  chest  and  taking  cold  the  previous  evening.  There 
was,  at  first,  a  slight  haemoptysis,  but  hardly  enough  to  create  the 
sub-crepitant  rale ;  and  some  febrile  symptoms  lasted  for  a  few- 
days.  In  one  year,  symptoms  of  tuberculous  disease  developed 
themselves;  and  in  six  months  more  the  patient  died  of  phthisis. 
Whether  this  disease,  in  its  incipient  state,  was  there  in  the  first 
place,  cannot  be  known.  Possibly  latent  arid  incipient  tubercles 
might  have  assisted  in  producing  the  pulmonary  apoplexy. 

PROGNOSIS. — The  prognosis,  in  the  case  of  pulmonary  apoplexy, 
is  not  very  favorable.  The  disease  supposes  an  antecedent  seri- 
ous affection  of  some  sort,  or  perhaps  a  complication  of  affections. 
By  its  irritation,  also,  and  its  disturbance  of  the  function  of  respi- 
ration, it  almost  necessarily  leads  to  other  ill  results. 

TREATMENT. — If  there  is  haemoptysis,  that  is  to  be  arrested,  as 
described  in  the  treatment  of  congestion.  If  febrile  action  is  ex- 
cited, that  should  be  treated  as  in  other  cases.  But,  in  regard  to 
the  removal  of  the  coagulated  blood,  remedial  means  can  accom- 
plish but  little.  Simple  expectorants  and  demulcents  to  relieve 
the  air  passages  and  allay  irritation,  may  prove  palliative.  If 
there  are  complications  of  other  diseases,  they  should  receive  prop- 
er attention,  and  so  should  the  general  health  of  the  patient. 


216  THOUACIC    DISEASES. 

CHAPTER  IX. 

PULMONARY  GANGRENE. 

I  use  the  phrase  pulmonary  gangrene,  in  accordance  with  com- 
mon professional  usage.  Pulmonary  mortification,  however,  would 
be  a  more  appropriate  designation,  as  the  phrase  is  not  intended  to 
be  limited  to  a  partial  destruction  of  the  parts,  but  simply  to  an 
entire  loss  of  vitality  and  sloughing. 

PATHOLOGY. — Pulmonary  gangrene  may  occur  either  as  a  pri- 
mary or  a  secondary  affection.  When  it  is  primary,  it  results  from 
a  reduced  state  of  the  blood,  in  which  the  vitality  or  nutrition  of 
the  part  is  not  sustained.  As  a  secondary  affection,  it  occurs  some- 
times in  asthenic  pneumonitis.  In  the  primary  form,  the  diseased 
part  is,  at  first,  infiltrated  with  a  thin  serous  liquid  which  is  an 
exudation  dependent  on  the  incipient  gangrene.  In  the  seconda- 
ry forai)  the  tissue  in  the  beginning,  is  hard  and  congested,  and 
situated  in  the  midst  of  an  inflamed  portion  of  the  parenchyma, 
This  difference  of  anatomical  character  in  the  part  affected,  at  the 
outset  of  the  disease,  is  essentially  all  that  distinguishes  the  pri- 
mary form  from  the  secondary.  They  soon  assume  essentially 
the  same  appearance. 

Sometimes  the  disease  occupies  a  large  portion  of  the  lung  ; 
and  sometimes  it  is  quite  limited.  Like  pneumonitis,  it  generally 
begins  in  the  lower  half  of  the  lung.  The  color  of  the  part  that 
has  perished,  is  mostly  a  dirty  olive  color  or  greenish  brown,, 
The  part  becomes  moist  and  of  the  consistence  of  an  engorged 
lung,  or  softer.  Sometimes,  it  is  even  diffluent. 

Sometimes  the  disease  of  pulmonary  gangrene  has  been  divi- 
ded into  three  stages.  The  first  embraces  the  period  in  which 
the  mortification  is  just  fully  established  ;  the  second,  that  in  which 
the  tissue  begins  to  break  down ;  and  the  third,  that  during  which 
a  cavity  exists.  After  the  explanation  which  I  have  elsewhere 
given  of  the  nature  of  mortification,  the  pathology  of  pulmonary 
gangrene  needs  no  further  illustration,  except  to  say,  that,  recov- 
ery takes  place  from  the  third  stage  only  ;  and,  when  it  begins,  a 


PULMONARY  GANGRENE.  217 

line  of  separation  and  a  kind  of  membrane  forms  between  the 
healthy  and  the  mortified  tissue.  As  the  gangrenous  portion 
sloughs,  this  membrane  becomes  a  kind  of  lining  to  the  cavity; 
and,  while  the  cavity  communicates  with  the  bronchi,  the  mem- 
brane gives  origin  to  the  formation  of  pus  ;  and,  though  delicate 
as  a  serous  membrane,  it  has  rather  the  character  of  a  mucous. 
After  the  communication  is  closed,  the  membrane  assumes  a  char- 
acter more  distinctly  serous  ;  and  then  the  cavity  is  gradually  ob- 
literated by  the  formation  of  areolar  tissue  within  the  cyst,  or  else 
it  remains,  without  closing,  during  the  individual's  life.  After  a 
cure  of  the  gangrene,  the  portion  of  the  lung  which  has  been  in- 
volved in  the  disease,  is  liable  to  remain  for  a  long  time,  more  or 
less  dense,  and  to  receive  somewhat  less  than  the  normal  propor- 
tion of  air. 

As  a  cavity  is  forming,  the  bronchial  tubes  resist  the  destructive 
process  longer  than  the  areolar  tissue  ;  but  the  bloodvessels  gener- 
ally hold  out  long  after  the  bronchi  have  yielded.  On  a  post 
mortem  examination,  they  are  frequently  seen  traversing  the  cav- 
ity. At  length,  however,  they  too  are  destroyed  ;  and,  sometimes, 
their  destruction  gives  rise  to  hemorrhage,  though  generally,  they 
do  not  slough,  till  after  the  blood  lias  ceased  to  circulate  in  them. 

The  immediate  cause  of  primary  pulmonary  gangrene,  is,  doubt* 
less,  the  influence  of  vitiated  and  poorly  vitalized  blood.  In  the 
secondary  affection,  too,  there  must  be  substantially  the  same  con- 
dition. The  remote  or  ultimate  causes  are  intemperate  habits, 
neglect  of  nutritious  and  wholesome  diet,  and  all  such  circumstan- 
ces as  tend  to  diminish  vitality  or  break  down  the  general  health 
of  the  patient. 

DIAGNOSIS. — -The  general  signs  of  pulmonary  gangrene  are 
fever,  with  a  small,  frequent,  irritable,  and  sometimes  exceedingly 
feeble  pulse  ;  loss  of  appetite  from  the  nauseating  character  of  the 
gangrenous  liquid  which  is  swallowed  ;  sometimes  diarrhoea  from 
the  effect  of  the  same  liquid  ;  dyspnoea  often  extreme ;  and  a  pe- 
culiar pale  or  lead  colored  condition  of  the  whole  skin  of  the 
patient. 

The  more  local  signs  of  this  disease,  are  cough,  expectoration, 
and  fetor  of  breath.  The  cough,  at  first,  resembles  that  of  ordi- 
28 


218  THORACIC    DISEASES. 

nary  bronchitis,  but  becomes  more  loose  and  paroxysmal,  with  the 
progress  of  the  disease.  The  paroxysms  are  caused  by  an  accum- 
ulation of  fluid  in  the  bronchi,  inducing  an  effort  to  throw  it  off; 
and  hence,  as  soon  as  the  object  is  gained,  the  effort  ceases,  until 
a  new  accumulation  renders  another  effort  necessary.  These  par- 
oxysms of  coughing,  are  sometimes  very  disturbing. 

The  sputa  in  the  second  stage  begin  to  contain  gangrenous 
matter ;  and,  during  the  third  stage,  they  remain  about  the  same, 
until  that  matter  is  all  discharged.  They  consist  of  a  thin  fetid 
liquid  which  not  unfrequently  is  stained  with  blood  that  flows 
from  sphacelated  vessels.  This  liquid  is  pathognomonic  of  the 
disease.  If  the  case  proceeds  to  a  fatal  termination,  the  sputa  in- 
crease in  quantity,  while  the  patient  is  gradually  sinking.  Dr.  Ger- 
hard says,  "  there  are  two  principal  varieties  of  the  gangrenous 
sputa.  One  consists  of  a  dark  thin  liquid  which  sometimes  re- 
sembles tobacco  juice  or  the  infusion  of  licorice,  occasionally 
containing  small  pieces  of  black  gangrenous  lung.  The  other 
consists  of  a  grayish-yellow  pasty  fluid  which  is  probably  a  mix- 
ture of  pus  and  gangrenous  liquid.  The  latter  occurs  most  fre- 
quently in  cases  following  pneumonia.  Both,  however,  are  ex- 
tremely fetid,  though  the  odor  differs  slightly." 

The  fetor  of  the  breath  is  peculiar,  and  it  begins  to  appear 
even  in  the  first  stage  of  the  disease.  It  is  greater,  however,  in 
the  second  and  the  third  stages,  in  which  the  sloughing  process  is 
going  on.  This  fetor,  as  well  as  the  sputa,  is  pathognomonic  of 
the  affection ;  and  the  former  is  sometimes  so  extreme,  as  to  ren- 
der the  room  of  the  patient  scarcely  endurable. 

The  physical  signs,  previous  to  the  third  stage,  are  very  limited. 
The  thin  serous  liquid  which  exudes,  in  primary  gangrene,  from 
the  affected  portion  of  the  lung,  may  be  sufficient  to  give  a  sub- 
crepitant  and  a  mucous  rale,  as  it  passes  through  the  tubes ;  but 
if  the  disease  be  limited  to  a  small  space,  and  that  deep-seated  in 
the  lung,  the  healthy  sounds  of  respiration  will  be  heard  as  usual. 
If  the  disease  be  extensive,  the  current  of  air  in  the  air  passages 
being  prevented,  the  respiratory  sounds  at  the  part  will  be  sup- 
pressed. Percussion  generally  maintains  about  the  normal  reson- 
ance, though  the  pulmonary  tissue,  infiltrated  with  serosity,  may 
yield  a  considerable  degree  of  dullness. 


PULMONARY  GANGRENE.  219 

After  a  cavity  has  formed,  the  auscultatory  signs  are  the  gur- 
gling rale,  cavernous  respiration,  and  pectoriloquy.  Besides  the 
gangrenous  exudation  already  referred  to,  and  which  continues 
till  the  mortifying  process  is  arrested,  there  is  the  formation  of  pus, 
as  soon  as  the  vital  powers  get  the  ascendency.  Of  course,  when 
the  cavity  is  of  considerable  size  especially,  the  quantity  of  liquid 
exuding  from  the  walls  is  sufficient  to  give  a  loud  and  constant 
gurgling, — one  the  extent  of  which  is  scarcely  equalled  in  tuber- 
culous disease,  as  in  that  cavities  are  rarely  so  large  and  do  not 
give  rise  to  so  much  liquid. 

When  the  gangrenous  matter  is  expectorated  and  the  cavity  is 
evacuated,  cavernous  respiration  and  pectoriloquy  appear.  The 
former  is  generally  full  and  distinct ;  but  the  latter,  unless  the  cav- 
ity is  large  and  near  the  surface,  has  not  as  clear  a  resonance  as  is 
afforded  by  the  harder  walls  of  a  tuberculous  cavity.  Such,  how- 
ever, may  be  the  size  and  situation  of  a  cavity,  as  to  give  am- 
phoric respiration  and  full  pectoriloquy. 

Percussion  is  resonant  in  proportion  to  the  size  of  the  cavity 
over  which  it  is  made,  and  the  proximity  of  the  cavity  to  the  sur- 
face. If  a  considerable  portion  of  the  lower  lobe  of  the  lung  is 
destroyed  by  the  gangrene,  the  resonance  will  be  very  great. 

When  gangrene  of  the  lungs  is  being  cured  and  cicatrization  is 
taking  place,  the  signs  of  a  cavity  disappear,  and  are  replaced  by 
the  sub-crepitant  and  mucous  rales  made  by  the  muco-purulent 
matter  in  the  tubes.  Bronchial  respiration  and  bronchophony  next 
appear,  and  finally  give  place  to  sounds  nearly  normal.  The 
vesicular  murmur,  however,  remains  for  a  long  time  feeble,  and 
very  commonly  never  fully  returns.  The  normal  resonance  on 
percussion,  in  due  time,  re-appears. 

PROGNOSIS. — The  prognosis  in  this  disease  depends  very  much 
on  the  situation  of  the  patient.  In  private  practice,  the  patient 
being  properly  treated  and  nursed,  recovery  is  effected  in  a  major- 
ity of  cases ;  but,  in  hospitals  and  other  places  in  which  proper 
attention  is  not  paid,  the  chances  are  on  the  side  of  death. 

TREATIMENT. — In  primary  pulmonary  gangrene,  the  treatment 
must  be  of  a  supporting  character.  Hence  tonics  and  stimulants, 


220  THORACIC    DISEASES. 

in  connection  with  expectorants,  are  indicated.  As  an  expector- 
ant, nothing  is  better  than  the  compound  sirup  of  lobelia  and  san- 
guinaria.  As  tonics  and  stimulants,  peruvian  bark,  polygala  sen- 
ega, and  asarum  canadense  are  good.  Even  wine,  porter,  and  nu- 
tritious food  may  be  freely  given. 

When  gangrene  succeeds  inflammation  of  the  lungs,  or  comes 
on  in  the  course  of  pneumonitis,  more  regard  must  be  had  to  the 
febrile  symptoms.  Indeed,  the  ordinary  treatment  of  pneumon- 
itis must  be  adopted,  with  some  modifications.  The  active  ton- 
ics and  stimulants  will  not,  to  a  great  extent,  be  well  borne.  The 
anti-febrile  corroborants  should  be  freely  employed,  such  as  ascle- 
pias  tuberosa,  corallorhiza  odontorhiza,  and  agents  of  that  class 
are  of  great  importance. 

In  this  disease  anti-septics  are  valuable,  such  as  charcoal,  yeast, 
&c.  A  solution  of  chlorinated  soda,  unless  it  proves  too  lax- 
ative, may  be  given,  in  doses  of  ten  or  twenty  drops,  every  three 
or  four  hours.  Chloride  of  lime,  too,  may  be  placed  in  the  pa- 
tient's apartment  and  near  his  head.  It  will  add  to  his  comfort, 
and  favor  his  recovery. 

The  lisual  regard  should  be  paid  to  the  secretions  generally; 
and,  in  some  cases,  an  irritating  plaster  or  other  external  stimu- 
lant is  of  service.  In  general,  however,  but  little  reliance  can  be 
placed  on  external  applications. 


CHAPTER  X. 

PULMONARY    (EDEMA. 

PATHOLOGY. — This  is  generally  described  as  an  effusion  of  serum 
into  the  areolar  tissue  of  the  lungs.  It  is  doubtless  true,  howev- 
er, that  a  portion  of  the  effusion  is  into  the  vesicles  and  the  small- 
est bronchial  tubes.  In  general,  the  characteristics  of  pulmonary 
redema  are  like  those  of  dropsy  in  the  areolar  tissue,  in  any  other 
portion  of  the  system.  In  fact,  the  disease  is  a  form  of  anasarca. 

When  it  exists,  it  generally  affects  both  lungs  nearly  equally ; 
and,  like  anasarca  elsewhere,  it  is  first  discovered  in  the  most  de- 
pendent portion  of  tlie  tissue  concerned.  This  is  simply  the  effect 


PULMONARY    (EDEMA.  221 

of  gravitation,  the  meshes  of  the  tissue  not  forming  perfect  cells, 
but  containing  interstices  communicating  with  one  another. 

When  a  portion  of  an  oedematous  lung  is  examined,  it  is  found 
to  be  of  a  pale  gray  or  yellowish  color ;  it  is  heavier  than  healthy 
lung  •  it  pits  on  pressure  ;  and  it  has  a  peculiar  crepitation.  When 
incised,  it  emits  a  spurious  and  transparent  liquid  which,  when 
fully  expressed,  leaves  the  lung  in  an  apparently  healthy  condi- 
tion. The  texture  of  the  organ  is  thus  proved  sound ;  while  its 
increased  density  and  diminished  ability  to  contain  air,  are  shown 
to  result  from  the  presence  of  the  contained  fluid. 

Pulmonary  O3dema  is  a  lesion  not  very  unfrequent  with  the 
aged,  though  it  is  often  to  be  regarded  only  as  a  part  of  general 
dropsy.  It  sometimes,  however,  appears, — not,  perhaps,  as  an  id- 
iopathic  disease, — but  as  the  principal  manifestation  of  a  dropsi- 
cal tendency.  It  has  sometimes  proved  the  immediate  cause  of 
death  at  the  termination  of  a  fever  which  has  been  badly  treated 
and  in  which  the  blood  has  become  watery  and  deprived  of  its 
vital  properties. 

DIAGNOSIS. — Dyspnoea  is  a  general  symptom  of  this  disease ; 
and  the  evidence  from  this  of  existing  pulmonary  oedema  is 
strengthened,  if  there  is  anarsaca  or  evident  dropsy  of  other  parts 
of  the  system.  Generally,  the  expectoration  is  not  great.  What 
is  raised  is  chiefly  aqueous  fluid,  a  little  foamy,  and  containing 
some  floating  mucus.  Sometimes,  however,  a  very  considerable 
.amount  of  liquid  is  coughed  up  and  otherwise  expectorated.  In 
one  marked  case  of  the  disease,  ending  fatally,  I  saw  the  patient 
a  little  before  arid  after  death,  which  was  sudden.  There  was 
general  dropsy ;  and,  after  death,  a  good  deal  of  watery  fluid  was 
pressed  from  the  lungs  out  of  the  mouth. 

The  prominent  physical  sign  is  a  coarse  crepitant  rale,  heard  at 
the  base  of  the  lungs,  or,  if  the  disease  is  extensive,  over  a  con- 
siderable portion  of  them.  The  bubbles  of  this  rale  are  some- 
what coarser  than  those  heard  in  pneumonitis ;  but  they  break 
even  more  rapidly,  arid  do  not  extend  in  long  trains,  from  one 
point  to  another. 

Percussion  is  but  little  altered.  With  the  liquid,  there  is  suffi- 
cient air  in  the  lungs  to  give  nearly  the  ordinary  resonance.  At 


222  THORACIC    DISEASES. 

any  rate,  as  both  sides  are  alike  affected,  we  have  not  the  advan- 
tage of  comparing  a  diseased  with  a  healthy  lung,  and  cannot, 
therefore,  as  well  judge  what  is  the  normal  sound. 

PROGNOSIS. — -The  prognosis  in  this  disease  is  generally  unfavor- 
able. If  the  lungs  are  extensively  affected,  as  shown  specially 
by  the  peculiar  crepitant  rale,  there  is  but  little  room  to  hope  for 
essential  improvement. 

TREATMENT. — Like  other  dropsies,  pulmonary  oedema  generally 
arises  from  disease  of  the  heart,  or  obstruction  of  some  large  blood- 
vessels. The  immediate  cause,  therefore,  must  bfe  sought  out, 
and,  if  possible,  removed.  As  palliative,  rather  than  curative 
means,  diuretic  and  diaphoretic  medicines  may  be  administered  : — 
also,  if  the  debility  of  the  patient  does  not  contra-indicate,  hydra- 
gogue  cathartics.  Of  course,  his  strength  must  be  sustained  by 
vegetable  bitter  tonics,  so  far  as  they  are  well  borne. 


CHAPTER  XL 

PLEURITIS. 
•v, 

The  term  pleuritis,  synonymous  with  the  more  common  word 
pleurisy,  signifies  inflammation  of  the  pleura;  and  pleura,  in 
Greek,  -/rXsupa,  signifies  the  serous  membrane  which  lines  the  in- 
ternal surface  of  the  thorax  and  covers  the  viscera.  Like  pneu- 
monitis,  pleuritis  never  takes  on  a  form  so  distinctly  chronic,  as 
that  which  bronchitis  sometimes  assumes.  It  sometimes,  howev- 
er, becomes  an  asthenic  and  latent  disease,  and  sometimes  comes 
on  as  the  sequela  of  some  other  affection.  In  its  usual  form,  it 
may  be  regarded  as  a  primary  or  idiopathic,  and  a  sthenic  disease. 
As  such,  it  is  properly  called  primary  sthenic  pleuritis. 


PLEUR1TIS.  223 

SECTION    I. 
PRIMARY  STHENIC  PLEURITIS. 

As  the  simple  term  pleuritis,  without  any  qualifying  epithet,  is 
generally  employed  in  this  sense,  I  shall,  for  brevity's  sake,  so  use 
it ;  and  only  use  qualifying  words  to  express  other  modifications- 
of  the  disease. 

PATHOLOGY. — Pleuritis,  in  the  sense  of  a  primary  and  sthenic 
disease,  is  divided  into  two  stages.  The  first  is  the  stage  of  in- 
flammation. When  it  commences,  the  small  blood-vessels  be- 
neath the  pleura,  are  distinctly  visible"  through  that  transparent 
membrane,  being  interwoven  in  various  directions,  and  forming  a 
thick  net-work  of  a  bright  red  color.  When  this  membrane  is 
detached,  it  is  found  to  be  but  slightly  changed  in  appearance, — - 
the  development  of  the  inflammation  being  really,  in  the  main,  in 
the  sub-serous  areolar  tissue,  rather  than  in  the  serous  itself.  The 
truth  is,  serous  tissues  generally  differ  from  mucous,  in  being  thin- 
ner, more  delicate,  and  supplied  only  with  the  very  smallest  blood- 
vessels, such  as  do  not  transmit  the  red  globules  of  the  blood  ; 
whereas  some  of  the  branchings  of  the  arteries  of  such  size  as  to 
convey  the  red  globules,  and  be  easily  traced,  pass  into  mucous 
tissues.  As  in  all  cases  of  inflammation,  effusion  or  extravasation 
is  liable  to  occur ;  so  in  pleuritis,  bright  red  spots  of  blood,  ef- 
fused or  extravasated  from  the  vessels,  are  sometimes  quite  nu- 
merously seen. 

In  pleuritis,  we  cannot  trace  the  gradual  progress 'of  the  in- 
flammation and  the  consequent  change  of  the  symptoms,  ajs  in 
bronchitis.  The  delicacy  of  the  parts  concerned,  and  their  con- 
nection with  the  nervo-vital  fluid,  cause  the  inflammation  rapidly 
to  reach  its  height;  and  then  the  reparative .process,  mostly  in  the 
granulating  form,  is  soon  established. 

The  second  stage,  which  is  that  of  effusion,  commences  at  this 
point.  If  my  readers  have  made  themselves  familiar  with  my 
views  of  the  reparative  process,  and  its  connection  with  inflamma- 
tion, as  illustrated  in  the  first  Division  of  the  first  Part  of  this 
work,  they  will  see  how  beautifully  the  pathology  there  given  is 


224  THORACIC    DISEASES. 

illustrated  in  the  progress  of  the  disease,  pleuritis.  Authors  have 
generally  spoken  of  a  secretion  of  two  kinds  of  matter,  at  the 
commencement  of  the  second  stage.  They  speak  of  a  liquid 
serous  secretion,  and  a  secretion  of  albuminous  matter  or  plastic 
lymph,  deposited  upon  the  pleura  in  little  flocculi,  but  liable  to  be 
rubbed  off  and  to  sink,  with  the  serum,  to  the  most  dependent 
portion  of  the  thorax.  The  serum  and  the  lymph  are  supposed  to 
be  secreted  in  different  proportions,  in  different  cases  of  pleuritis, 
— the  former  being  very  small  in  amount,  in  some  cases,  called 
those  of  dry  pleuritis,  while,  in  other  cases,  it  is  very  abundant, 
and  fills  almost  the  r  whole  pleural  sac.  The  serum  is  of  a  whit- 
ish or  yellowish  color,  and  never  perfectly  limpid.  It  is  clearly 
the  watery  or  essentially  the  unorganized  portion  of  the  blood. 
In  regard  to  the  "  effusion  of  lymph,"  as  it  has  been  called,  Dr. 
Gerhard  speaks  particularly,  in  connection  with  some  reference  to 
the  serous  deposit.  He  says,  "  This  effusion,  the  effusion  of 
lymph,  is  at  first  deposited  on  the  serous  surface,  in  minute  points, 
which  are  transparent  and  scarcely  visible,  but  may  be  readily  de- 
tected by  the  touch.  These  points,  as  they  become  more  numer- 
ous, gradually  collect  into  groups  which,  finally  coalescing,  form 
a  continuous  membrane.  The  deposit  of  lymph  has  received  the 
name  of  a  false  membrane,  and  is  more  abundant  at  the  lower 
portions,  where  it  is,  in  some  cases,  as  much  as  a  fourth  or  even 
half  of  an  inch  in  thickness,  while,  at  the  upper  portion,  it  sel- 
dom exceeds  an  eighth  of  an  inch.  The  character  and  the 
amount  of  the  effusion  vary,  according  to  the  form  of  the  disease 
and  the  constitution  of  the  individual  affected.  In  cases  of  local 
pleurisy,  especially  if  occurring  in  robust  persons,  the  amount  of 
serum  effused  is  very  small,  while  there  is  a  considerable  deposit 
of  lymph.  The  same,  also,  occurs  in  persons  who  are  not  robust, 
when  the  inflammation  is  confined  to  a  small  portion  of  the  mem- 
brane. On  the  contrary,  if  the  patient  be  thin,  and  of  a  lym- 
phatic temperament,  and  the  inflammation  diffused,  the  effusion 
of  serum  will  be  very  great,  with  but  a  slight  trace  of  lymph. 
The  thin  and  serous  part  of  the  effusion  tends  to  diffuse  itself 
over  the  surface  of  the  pleura,  gravitating  to  the  most  dependent 
portion,  and  shifting  its  position,  with  the  movement  of  the  pa- 
tient. When,  however,  it  is  principally  composed  of  lymph,  it  is 


PLEURITIS.  225 

confined  to  the  part  of  the  lung  which  is  affected,  and  exhibits  no 
such  tendency.  The  serum  increases  in  quantity,  as  the  disease 
advances,  and  decreases  with  its  decline.  But  the  lymph  is  more 
persistent  in  character ;  and,  instead  of  being  removed,  becomes 
organized,  and  assumes  the  character  of  a  serous  or  cellular  mem- 

^  ' 

brane,  according  to  the  circumstances  in  which  it  is  placed." 

This  quotation  from  Dr.  Gerhard,  contains  substantially  the 
views  of  pathologists  generally  on  this  subject ;  and  to  my  own 
mind,  it  seems  strange,  that  they  could  have  mistaken  the  truth 
for  so  long  a  time,  and  yet  not  have  fallen  upon  it,  in  all  its  sim- 
plicity. 

In  the  deposit  of  the  hyaline  fluid,  and  the  formation  of  new 
tissue,  it  will  be  remembered,  that  the  liquor  sanguinis  is  at  first 
secreted.  This  is  composed  of  a  little  less  than  three  parts  of 
fibrin,  and  more  than  eight  hundred  and  fifty  of  serum  in  one 
thousand  parts  of  blood.  The  fibrin  is  essentially  the  only 
portion  used  in  forming  the  hyaline  deposit,  while  the  serum,  not 
entering  into  the  vital  economy,  has  to  be  otherwise  disposed  of. 
When  a  surface  exposed  to  the  external  world  heals,  the  serum  is 
mainly  evaporated  ;  but  in  a  shut  sac,  like  that  of  the  pleura,  it 
must  either  be  absorbed  or  fall  to  the  bottom.  In  persons  possess- 
ing a  good  deal  of  vital  energy,  the  absorption  may  go  on  nearly 
or  quite  as  fast -as  the  serum  is  'separated  -from  the  fibrin;  and 
hence  the  pleuritis  is  called  dry.  In  persons  of  a  lymphatic  tem- 
perament or  those  whose  general  health  has  become  much  im- 
paired, the  power  of  absorption  will  be  diminished,  while  the 
blood  itself,  from  which  the  hyaline  fluid  is  taken,  is  liable  to 
have  too  small  a  proportion  of  fibrin,  and  too  large  a  proportion 
of  serum.  Of  course,  under  these  circumstances,  there  must  nec- 
essarily be  a  collection  of  serum  in  the  pleural  sac. 

In  the  formation  of  false  membrane,  as  it  is  called,  I  have  else- 
where explained,  that  the  process  is  only  the  granulating  process, 
or  union  of  the  parts  by  granulations.  This,  too,  I  have  said,  is 
mainly  a  vital,  though  in  part  a  chemical  process.  It  shows  the 
disposition  of  tissues  to  heal,  not  by  means  of  inflammation,  but 
in  spite  of  the  existing  inflammation.  In  the  case  of  the  pleura, 
the  exudation  corpuscles  appear  on  the  surface,  at  first  in  distinct 
.points ;  but  they  accumulate  near  together,  and  finally  form  a 
29 


226  THOKACIC    DISEASES. 

membrane.  The  rubbing  of  the  two  parts  of  the  pleura  together, 
fritters  away  a  portion  of  these  exudations,  and  they  mingle  with 
the  serum  collected  in  the  sac.  The  fact  that  the  pulmonary  and 
the  costal  portions  of  the  pleura  often  unite,  is  strictly  an  accident. 
They  bejmg  in  contact,  while  the  reparative  process  is  going  on, 
cannot  escape  the  accident,  except  the  rubbing  of  the  parts  to- 
gether in  respiration,  prevents ;  but  this  is  not  likely  to  obviate  that 
result.  While  there  is  a  collection  of  water  in  a  portion  of  the 
cavity,  that  prevents  the  accident ;  but,  after  the  water  is  absorbed, 
it  generally  occurs. 

As  the  serum  is  absorbed  in  the  progress  of  recovery,  the  pres- 
sure of  the  atmosphere  without,  forces  the  parietes  of  the  thorax 
towards  the  lung,  and  adhesion  takes  place  between  the  two  sur- 
faces of  the  pleura.  The  lung  is  compressed  against  the  spine, 
and,  in  that  position  is  covered  with  exudations  or  false  membrane, 
so  that  it  cannot  afterwards  rise  to  meet  the  ribs.  When  the 
pleuritis  is  slight  and  the  effusion  small,  there  is  little  or  no  con- 
traction of  the  chest.  If  there  is  some,  at  the  time,  it  does  not 
remain  permanent,  but,  after  a  while,  the  lung  expands  in  a  good 
degree.* 

But  when  the  pleuritis  is  severe,  and  the  effusion  great,  the  size 
of  the  lung  by  the  pressure  of  the  effused  fluid,  is  greatly  dimin- 
ished. To  its  normal  dimensions  after  a  very  great  compression, 
it  seldom  returns.  And  yet,  by  this,  its  structure  is  often  unaf- 
fected. In  appearance,  it  is  wrinkled  and  flaccid,  not  crepitating, 
and  containing  but  little  blood.  By  surrounding  inflammation,  it 
is  but  little  affected.  For  the  tendency  of  serous  inflammations  to 
implicate  subjacent  tissues,  is  but  slight.  Air  forcibly  blown  into 
its  branches,  readily  distends  it  nearly  to  its  original  size.  Some- 
times, however,  its  vesicles  adhere,  and  thus  the  ingress  of  air  is 
prevented.  Then  it  looks  like  apiece  of  flesh,  and  is  said  to  be 
carnified.  The  small  size  to  which  the  lung  in  the  chronic  form 
of  the  disease,  is  sometimes  reduced  by  the  effusion,  and  its  con- 
cealment beneath  thick  layers  of  false  membrane,  led  the  ancient 
pathologists  to  conclude,  that  the  lung  itself  was  entirely  destroyed 
by  suppuration. 

*  Here  ends  the  writing  of  Dr.  Newton. 


PLEUR1TIS.  227 

Such  a  degree  of  atrophy  remaining  permanent,  after  the  ab- 
sorption of  effusion,  would,  of  course,  cause  a  vacant  space  in  the 
chest,  and  this  gives  rise  to  contraction  of  its  walls,  and  to  an  el- 
evation of  the  subjacent  viscera,  the  degree  of  which  will  depend 
upon  the  size  of  the  space,  left  vacant  by  the  removal  of  effused 
fluids. 

The  quantity  of  effused  fluid  varies  from  a  few  ounces  to  sev- 
eral pints.  When  very  copious,  it  fills  the  cavity  of  the  pleura, 
and,  in  some  cases,  has  been  known  in  the  course  of  a  few  days, 
largely  to  distend  the  chest,  to  cause  the  intercostal  spaces  to  be- 
come more  prominent  than  usual,  and  by  its  pressure  to  displace 
the  adjacent  viscera,  whether  of  the  thorax  or  abdomen.  But 
these  results  more  frequently  take  place  in  the  more  protracted 
cases  which  more  properly  may  be  described  under  the  head  of 
chronic  pleurisy. 

In  the  sthenic  form  of  the  disease,  the  distension  is  rarely  very 
great.  In  character  the  liquid  is  usually  yellowish,  limpid,  or 
slightly  clouded  with  flocculi  of  concrete  albumen  floating  in  it. 
Often  it  is  turbid,  like  whey,  sometimes  bloody  with  or  without 
coagula.  In  short,  its  color  generally  varies  according  to  the  va- 
riable quantity  of  its  contained  blood  or  of  its  red  globules.  In 
the  progress  of  the  disease,  there  are,  moreover,  mingled  in  the 
effusion,  more  or  less  of  coagulable  lymph  and  pus.  In  ordinary 
cases  it  has  but  little  odor.  This,  however,  is  not  always  the  case. 
Gangrene  of  a  portion  of  the  lung,  or  the  admission  of  air  into 
the  pleural  sac,  constituting  pneumothorax,  often  makes  its  odor 
most  offensive  from  the  generation  as  some  suppose,  of  sulphure- 
ted  hydrogen  gas  by  decomposition. 

During  the  progress  of  the  disease,  the  proper  serous  membrane, 
or  the  epithelium  upon  the  areolo-fibrous  layer,  is  not  thickened 
or  materially  softened.  In  fact,  the  inflammation  of  serous  mem- 
branes generally  is  located  in  the  areolo-fibrous  layer,  because 
this  is  vesicular,  and,  therefore,  more  subject  to  inflammation. 
Whether  or  not  the  pleura  pulmonalis  is  more  liable  to  take  on 
inflammatory  action  than  the  pleura  costalis,  authors,  generally,  to 
my  knowledge,  do  not  express  an  opinion.  That  pneurnonitis 
often  extends  inflammatory  action  to  the  pleura,  and  that  tubercu- 
lar deposits,  adjacent  to  the  surface  of  the  lung,  often  cause  a  sim- 


228  THORACIC    DISEASES. 

ilar  effect,  are  facts  well  known  to  medical  men.  And  hence,  it 
seems  reasonable  to  conclude,  that  inflammation  at  first  more 
often  affects  the  pleura  pulmonalis,  and  that  the  affection  of  the 
costal  membrane  is  secondary. 

The  adhesions  of  some  parts  of  the  lung  are  more  strong,  and 
more  often  occur  than  those  of  others.  Whether  or  not  adhesion 
shall  take  place  at  all,  will  depend  on  the  quantity  of  serous  effu- 
sion, and  the  character  of  its  coagulable  lymph  poured  out  on  the 
pleural  surfaces.  Of  course,  the  fluid  would  ponderate  to  the  low- 
est part  of  the  chest,  and  pressing  apart  the  two  surfaces  of  the 
pleura,  would  prevent  adhesion.  If  the  upper  portion  is  inflamed, 
and  the  fluid  is  not  so  copious  as  to  fill  the  entire  pleural  sac,  the 
part  of  the  lung  above  the  surface  of  the  fluid,  will  adhere,  while 
the  parts  below  will  remain  free.  But  if  the  pleura?  be  inflamed 
in  their  lower  portions  only,  a  moderate  quantity  of  liquid  will  be 
enough  to  keep  their  surfaces  separate  ;  and,  if  the  lymph  then  be- 
comes organized,  it  forms,  not  an  adhesion,  but  a  false  membrane 
coating  the  lung,  which  may  have  effects  in  modifying  the  remains, 
or  the  products  of  previous  inflammation. 

A  second  condition  modifying  the  liability  to  adhesion,  is  the 
composition  of  the  coagalable  lymph.  If  this  contains  a  large 
proportion  of  xvhat  Mr.  Paget  calls  the  fibrinons  lymph,  or,  in 
other  words,  if  the  lymph  partakes  more  of  the  jibrinous,  than  of 
the  corpuscular  character,  the  liability  to  early  adhesion  will  be 
increased.  When  little  or  no  liquid  exists  to  prevent  contact  of  sur- 
faces, the  union,  when  the  fibrinous  lymph  is  exuded,  takes 
place  in  a  short  time.  As  absorption  removes  the  fluid,  the 
lymph  becomes  organized,  adhesion  is  the  result,  and  in  this  man- 
ner, many  times  nearly  the  whole  pleural  sac  is  obliterated.  When 
this  is  the  case,  that  side  so  affected  is  not  liable  afterward  to  take 
on  pleuritic  inflammation.  In  some  cases,  the  adhesion  is  only 
partial.  Sometimes  filiaments  of  cellular  membrane  are  seen  ex- 
tending from  one  surface  to  the  other,  having  been  formed,  prob- 
ably, during  the  plastic  state  of  the  effused  lymph,  by  the  move- 
ment of  the  lung  upon  the  side  of  the  chest  in  respiration,  draw- 
ing out  the  lymph  into  slender  connecting  bands. 

There  are  cases  in  which,  contrary  to  common  experience,  the 
lower  parts  of'  the  lung  are  firmly  bound  down  to  the  parietes  of 


PLEURITIS.  229 

the  chest,  while  the  upper  parts  are  free.  A  new  attack  of  pleuri- 
sy on  the  same  side,  under  these  circumstances  will,  of  course, 
cause  effusion  from  the  upper  and  free  surface  of  the  lung,  and  in 
this  way  give  rise  to  abnormal  sounds  on  percussion,  in  a  locality, 
where  by  the  inexperienced  physician,  they  would  not  be  suspected. 

Another  effect  of  pleuritis  is  the  formation  of  pus.  This,  how- 
ever, in  cases  of  sthenic  pleurisy,  is  gradual.  In  the  advanced 
stages  only,  it  assumes  the  character  of  pure  pus.  In  fatal  cases 
terminating  after  a  few  weeks,  the  effusion  is  thin,  and  is  evident- 
ly composed  in  part  of  serum.  And  hence  it  has  received  the 
very  appropriate  name,  sero-purulent  effusion.  It  is  probable,  also 
that  in  the  earlier  stage  of  the  disease,  a  certain  nmnber  of  pus 
globules  exist  in  the  effused  serum. 

"  Sometimes,  in  persons  of  feeble  constitution,"  says  Dr.  Swett, 
"  there  are  cases  which,  if  measured  by  the  time  the  disease  had 
existed,  would  be  called  cases  of  chronic  pleurisy,  but,  in  which 
after  death  an  abundant  serous  effusion,  and  but  very  little  lymph 
or  pus  exist." 

Such  cases  seem  to  be  developed  by  the  existence  of  a  low  de- 
gree of  inflammatory  action  which  does  not  advance  much  beyond 
the  effusion  of  serum,  but  which,  occurring  in  feeble  constitutions, 
and  developed  insidiously,  is  protracted  to  a  fatal  termination.  On 
the  contrary,  the  formation  of  pus  is  not  always  so  protracted  as 
before  described.  When  the  inflammation  is  violent,  in  its  char- 
acter, pus  may  be  secreted  in  the  acute  stage  of  the  disease,  and 
a  fatal  termination  is  quickly  the  result.  The  existence  of  pus 
alone  in  the  cavity  of  the  chest,  cannot,  therefore,  be  justly  con- 
sidered as  a  sure  indication  of  the  stage  of  the  disease.  For  the 
time  of  its  formation  depends  very  much  upon  the  constitution 
and  temperament  of  the  patient.  Casteris  paribus  early  adhesions, 
instead  of  copious  effusion  of  serum,  or  the  formation  of  pus, 
take  place  in  mild  cases,  and  in  the  young,  strong  and  healthy. 
On  the  contrary,  in  the  feeble,  old,  and  scrofulous,  the  effusion  of 
serum  of  a  puriform  character  more  frequently  occurs  early  in  the 
disease.  The  cause  of  this  is  found  in  the  varied  character  of 
the  effused  lymph.  In  the  young  and  plethoric,  in  those  whose 
blood  is  rich  in  fibrin,  the  fibrinous  lymph — using  the  division  of 
lymph  as  made  by  Mr.  Paget — is  most  commonly  effused.  While 


230  THORACIC    DISEASES. 

in  persons  having  blood  of  an  opposite  character,  the  effused 
lymph  partakes  more  of  the  corpuscular  or  less  vitalized  form 
which,  very  readily,  and  with  but  little  change,  degenerates  into 
pus. 

DIAGNOSIS. —  General  and  rational  symptoms.  Acute  sthenic 
pleuritis  usually  commences  with  a  chill,  soon  succeeded  by  an 
acute  lancinating  pain  in  the  side,  cough,  short  and  quick  breath- 
ing, and  fever.  Each  of  these  will  receive  a  particular  notice. 

The  pain  may  come  on  either  before,  at  the  same  time,  or  a 
short  time  after  the  chill.  In  character,  it  is  severe  as  if  resulting 
from  the  thrust  of  an  instrument,  and  hence,  it  is  often  called  a 
stitch  in  the  side.  Usually  it  is  felt  somewhere  in  the  mammary 
region.  But  sometimes,  elsewhere ;  sometimes  near  the  lower 
margin  of  the  chest,  in  which  case  it  is,  probably,  the  result  of 
inflammation  of  that  part  of  the  pleura  which  covers  the  dia- 
phragm. In  most  cases  it  is  confined  to  one  place,  but  it  may  be 
diffused  over  the  surface  of  the  chest,  when  it  is  sudden,  very 
sharp  and  severe.  It  is  so  nearly  simulated  by  the  nervous  pains  of 
hysteria,  that  it  may  lead  to  error  in  diagnosis.  By  inspiration, 
cough  and  motion,  it  is  increased.  Generally,  lying  on  the  af- 
fected side,  and  pressure  over  the  intercostal  spaces,  aggravate  it. 
There  is,  a  day  or  two  after  the  occurrence  of  the  most  severe 
pain,  a  greater  degree  of  soreness  externally,  than  when  early  in 
the  disease,  the  pain  is  most  acute.  As  the  effusion  increases,  the 
pain  decreases  in  consequence  of  the  separation  of  the  inflamed 
membranes  by  the  fluid,  and  the  prevention  of  friction.  It  is,  in 
some  cases,  almost  entirely  wanting,  being  perceptible  only  as 
soreness  on  pressure. 

The  cough  is  usually  short  and  dry,  attended  with  but  little 
expectoration  of  mucus  or  frothy  matter.  Sometimes  a  more  co- 
pious expectoration  is  present.  When  the  pleuritis  is  complicated 
with  a  degree  of  bronchitis,  it  is  occasionally,  somewhat  bloody. 
Severe  pain  often  attends  it,  to  avoid  which,  the  patient  tries  to 
suppress  the  cough,  and  to  a  certain  extent  he  succeeds  by  the  effort. 
This,  however,  in  some  cases  is  wanting.  When  such  is  the  fact, 
and  there  is  at  the  same  time  no  pain,  the  disease  by  some  au- 
thors is  called  latent  pleurisy. 


PLEURITIS.  231 

The  breathing,  in  most  cases,  is  more  or  less  difficult.  The 
pain  prevents  a  full,  deep  inspiration.  The  patient  is  said  to  have 
a  catch  in  his  breath.  In  consequence  of  this,  less  air  is  taken 
into  the  lung  when  the  pleura  is  affected,  and  the  frequency  of  res- 
piration is  therefore  increased  inversely  as  the  quantity  of  inspired 
air  at  each  inspiration  decreases.  The  dyspno3a,  unlike  the  pain, 
increases  as  the  disease  advances.  The  effused  fluid  filling  up 
the  space,  usually  occupied  by  the  lung,  causes  this  symptom. 
The  function  of  one  lung  is  more  or  less  suspended,  and  the  ac- 
tion of  the  other  is  increased  beyond  its  normal  degree  ;  so  that 
the  breathing  of  the  patient  becomes  painful,  and  difficult.  This 
is  more  particularly  the  case,  when  the  effusion  is  both  sudden 
and  copious.  When  gradual,  the  system  accustoms  itself  to  the 
abnormal  conditions  of  the  respiratory  organs.  In  the  latter  stag- 
es it  is  most  severe. 

The  decubitus  has  been  considered  as  a  pathognomonic  sign  of 
the  disease.  Yet  there  is  much  variance  among  the  opinions  of 
observers  in  respect  to  this  symptom.  This  results  from  the  va- 
riation of  the  decubitus  in  the  different  stages  of  pleuritis.  At 
first,  the  patient  cannot  lay  upon  the  affected  side,  on  account  of 
the  increase  of  pain  which  that  position  produces.  At  a  later  pe- 
riod, when  the  effusion  separates  the  inflamed  surfaces,  the  pain, 
resulting  from  the  position  of  the  two  portions  of  the  pleurae,  be- 
comes less,  and  sometimes  is  entirely  wanting.  When  the  decu- 
bitus is  on  the  sound  lung,  the  weight  of  the  effused  fluid,  press- 
ing upon  the  mediastinum,  and  forcing  this  beyond  the  median 
line,  preventing  the  ingress  of  air  into  the  sound  lung,  causes 
pain  from  dyspnosa.  And,  consequently,  at  this  period  of  the  dis- 
ease, the  decubitus  is  most  free  from  unpleasant  sensations  on  the 
affected  side. 

The  fever  is  usually  considerable,  and  attended  with  the  most 
common  phenomena  of  febrile  affections.  The  pulse  is  quick, 
sometimes  rising  to  over  a  hundred  beats  in  a  minute,  hard,  full 
and  tense.  The  skin  is  dry  and  hot,  particularly  over  the  chest, 
or  the  seat  of  the  disease. 

The  tongue  is  parched ;  the  urine  is  scanty  and  high  colored ; 
and  occasionally  there  are  cerebral  symptoms.  Of  the  fever  there 
are  often  daily  remissions  and  exacerbations,  the  former  coming 


232  THORACIC    DISEASES. 

on  in  the  morning,  the  latter  in  the  afternoon  or  evening.  In 
four  or  five  days  it  moderates  considerably. 

"  The  physical  signs ,  at  the  commencement  of  the  attack,  are 
nearly  normal.  Before  effusion  has  taken  place,  percussion  is 
quite  clear,  and  no  auscultatory  sign  is  given,  except  a  slight  di- 
minution of  the  respiratory  murmur,  consequent  upon  the  defi- 
cient expansion  of  the  lung,  which  is  rendered  more  evident  by  a 
comparison  of  the  two  sides.  As  this  depends  nearly  upon  the 
pain  of  inspiration,  it  is  obvious  that  the  same  result  must  take 
place  in  all  other  cases  in  which  the  pain  is  equally  acute,  and  es- 
pecially in  pleurodynia;  so  that  the  sign  is  of  no  great  value. 
But  very  soon  after  the  onset  of  the  disease,  when  the  concrete 
exudation  has  had  time  to  cover  in  some  degree,  the  surface  of 
the  membrane,  a  peculiar  and  characteristic  sound  may  often  be 
heard,  in  the  middle  portion  of  the  chest.  Sometimes  it  is  ac- 
companied by  a  tremor  when  the  hand  is  applied  to  the  affected 
side.  This  is  the  friction  sound,  produced  by  the  rubbing  of  the 
opposite  roughened  surfaces  against  each  other.  It  is  thought 
that  the  sound  may  be  developed  even  before  the  commencement 
of  exudation  by  the  rubbing  together  of  the  pleuritic  surfaces, 
rendered  dry  by  the  commencing  inflammation,  or  unequal  by  the 
enlarged  vessels.  The  grating  movement  which  gives  rise  to  the 
sound,  may  be  felt  by  the  hand  applied  to  the  side.  As  the  con- 
ditions upon  which  the  sound  depends,  are  of  short  duration,  the 
sign  must  be  evanescent.  It  must  vanish  whenever  a  union  of  the 
opposite  surfaces  takes  place,  or  as  soon  as  they  are  separated  by 
the  liquid  effusion.  Although,  from  its  uncertain  occurrence,  and 
its  fugitive  character,  it  cannot  always  be  depended  on,  yet,  when 
observed,  it  is  a  valuable  sign,  especially,  in  cases  unattended  with 
liquid  effusion,  such  as  have  sometimes  been  called  dry  pleurisy. 

"  The  most  decisive  signs  are  those  afforded  after  liquid  effusion 
has  commenced.  A  diminution  of  the  healthy  resonance  on 
percussion  may  very  soon  be  perceived  by  a  comparison  of  the 
opposite  sides,  and  the  dullness  goes  on  increasing  with  the  in- 
crease of  the  effusion,  until  at  length  it  often  amounts  to  perfect 
flatness.  At  first,  it  is  observed  in  the  most  dependant  parts  of 
the  chest,  and  rises  higher  and  higher  with  the  advance  of  the 
disease.  It  usually  varies  with  the  position  of  the  patient,  fol- 


233 

lowing,  of  course,  the  position  of  the  liquid  which  necessarily 
gravitates  to  the  most  dependent  part,  while  the  lung,  which  is 
lighter,  has  a  tendency  to  float  above  it.  The  only  exceptions 
to  this  rule,  are  cases  in  which  the  lung,  and,  consequently,  the 
liquid,  are  confined  by  adhesions,  and  those  in  which  the  whole 
cavity  is  filled  with  the  effusion.  In  the  latter  case  flatness  is 
universal  over  the  affected  side  of  the  chest.  Sometimes,  when 
a  small  portion  of  the  lung  is  in  contact  with  the  walls  of  the 
chest,  while  all  the  rest  is  separated  from  them  by  effusion,  a 
tympanitic  sound  is  yielded  on  percussion,  which  might  be  mis- 
taken as  the  sign  of  pneumothorax  or  of  a  pulmonary  cavity. 

"  The  respiratory  murmur,  somewhat  enfeebled  by  the  defective 
movement  of  the  lung  from  pain,  is  still  more  so  when  liquid  ef- 
fusion takes  place,  and  goes  on  diminishing  with  the  increase  of 
effusion,  and  of  the  consequent  compression  of  the  lung,  until  it 
entirely  ceases  in  those  cases  in  which  the  liquid  is  abundant. 
In  parts  in  which  the  lung  is  still  in  contact  with  the  chest,  the 
healthy  murmur  is  often  superseded  by  bronchial  respiration,  de- 
pendent upon  the  compression  of  the  air-cells,  which  thus  more 
readily  convey  the  vibrations  of  the  bronchi  to  the  surface.  This 
sound  is  usually  greatest  near  the  root  of  the  lung,  and  diminish- 
es as  we  recede  from  that  part,  though  it  often  extends  more  or 
less  over  the  whole  side  of  the  chest.  But,  when  the  effusion  is 
very  abundant,  this  sound  alone  is  quite  lost,  except  in  the  region 
between  the  scapulae,  and  sometimes  even  there.  On  the  opposite 
side  of  the  chest,  the  respiration  is  louder  than  is  usual  in  health, 
and  often  becomes  puerile. 

"  The  vocal  resonance,  increased  at  first  while  the  exudation  is 
plastic,  becomes,  at  a  somewhat  more  advanced  stage  of  the  dis- 
ease, quite  peculiar.  When  a  moderate  effusion  has  taken  place, 
and  a  thin  stratum  of  liquid  intervenes  between  the  lung  arid  side 
of  the  chest,  the  tremulous,  quivering,  or  _bleating  sound  of  the 
voice  denominated  egophony  is  heard.  The  bronchial  sound,  con- 
veyed outward  by  the  compressed  parenchyma,  is  modified  as  it 
passes  through  the  trembling  liquid,  and  acquires  the  striking 
character  alluded  to,  before  it  reaches  the  ear.  This^modified 
sound  is  heard,  especially  between  the  third  and  sixth  ribs,  in  the 
30 


234  THORACIC    OfSEASES. 

interscapular  regions,  and  between  the  scapulae  and  mammse.  It 
is  most  obvious  in  women  and  children,  in  consequence  of  the 
higher  tone  of  their  voice.  Over  the  larger  bronchi,  near  the 
spine,  for  example,  it  is  often  mingled  with  the  bronchial  reson- 
ance, and  the  sound  acquires  a  peculiar  complex  character.  As 
the  effusion  increases,  egophony  diminishes,  and  at  length  ceases 
altogether.  Dr.  Williams  is  of  opinion,  that  little  sound  of  the 
voice  is  transmitted  when  the  stratum  of  intervening  liquid  ex- 
ceeds an  inch  in  thickness,  except  over  the  larger  tubes.  When 
the  quantity  of  liquid  is  very  great,  no  vocal  resonance  is  heard, 
except  in  a  narrow  space  upon  the  side  of  the  spine. 

"  These  results  are  of  course  modified,  when  the  lung  adheres 
more  or  less  extensively  to  the  sides  of  the  chest.  In  such  cases, 
the  bronchial  resonance  is  usually  loud  and  distinct  at  the  adher- 
ing parts  in  consequence  of  the  compression  of  the  air-cells. 
When  the  extent  of  adhesion  is  small,  the  compressed  lung  forms 
a  column,  or  kind  of  internal  stethoscope,  for  conveying  the 
sound  to  the  ear.  The  vibratory  movements  of  the  walls  of  the 
chest  are  affected  similarly  with  the  sound  of  the  voice,  being 
somewhat  increased  so  long  as  the  effusion  is  plastic,  gradually 
diminished  with  the  increase  of  liquid,  and  entirely  suppressed 
where  the  intervening  effusion  is  copious,  but  still  distinctly  ob- 
servable where  the  lung  adheres.  Hence,  when  one  hand  is 
placed  upon  the  sound  side,  and  the  other  upon  the  diseased  one, 
and  the  patient  is  told  to  speak,  little  or  no  movement  is  felt  in 
the  latter,  with  the  exception  just  mentioned,  while  in  the  former 
the  thrill  is  distinct. 

"  Besides  the  above  signs,  there  are  others  derived  from  the 
movements  and  shape  of  the  chest,  and  the  relative  positions  of 
neighboring  organs.  Thus,  the  affected  side  may  be  observed  to 
be  quiescent,  while  the  other  moves  in  respiration.  When  effu- 
sion is  great,  the  chest  may  be  visibly  distended,  and,  if  meas- 
ured by  a  tape,  in  the  direction  of  a  line  around  the  body  at  the 
scrobiculus  cordis,  it  will  be  found  to  be  larger  on  the  diseased 
than  on  the  sound  side.  This,  however,  is  not  common,  to  any 
great  extent,  in  acute  pleurisy.  Any  difference  that  may  exist 
will  be  most  readily  detected  by  making  the  measurement  at  the 
moment  of  full  expiration,  as  it  is  then  greatest  in  consequence 


PLEUB.ITIS.  235 

of  the  non-contraction  of  the  distended  side.  But  the  fact  must 
always  be  taken  into  account,  that  the  right  side  in  health  ordin- 
arily measures  from  a  quarter  to  a  half  an  inch  more  than  the 
left.  The  displacement  of  the  heart,  liver,  etc.,  is  much  more 
frequently  to  be  observed  in  the  chronic  than  in  the  acute  form 
of  the  disease. 

"  The  course  of  acute  or  sthenic  pleuritis  is  very  variable  and 
uncertain.  There  is  reason  to  believe  that,  if  the  disease  is  vig- 
orously treated  at  the  beginning,  it  may  often  be  arrested  almost 
at  the  threshold,  before  it  has  exhibited  any  other  signs  of  its 
existence  than  pain,  decubitus  on  the  sound  side,  a  little  cough,  and 
a  chill  followed  by  fever.  Exudation  not  having  yet  taken  place, 
the  physical  signs  are  wanting.  Should  a  catarrhal  cough  have 
preceded  the  attack,  or  should  no  cough  exist,  as  sometimes 
happens,  there  are  no  means  by  which  the  disease  could  be  cer- 
tainly distinguished  from  febrile  pleurodynia.  which  has  the 
general  symptoms  above  mentioned,  and  the  same  diminution  of 
the  respiratory  murmur,  arising  from  the  restrained  movements  of 
the  chest.  Hence,  the  doubt,  in  these  cases,  whether  it  was 
pleurisy  or  rheumatism  of  the  intercostals,  that  was  cured. 

"  In  other  cases,  along  with  the  general  symptoms  mentioned, 
there  is  the  friction  sound  upon  auscultation,  which  is  sufficiently 
decisive  as  to  the  nature  of  the  complaint.  The  effusion  of 
coagulable  lymph  has  probably  taken  place,  and  a  longer  period  is 
necessary  for  the  cure.  .  Sometimes,  however,  the  morbid  phe- 
nomena wholly  disappear  in  from  three  to  five  days,  leaving  no 
unhealthy  sound  in  the  chest.  In  such  cases,  the  opposite  sur- 
faces of  the  pleura  have  united,  and  the  friction  sound  ceases, 
because  the  surfaces  do  not  move  on  each  other. 

"In  a  third  class  of  cases,  the  signs  of  liquid  effusion  are  per- 
ceived sometimes  on  the  first  day ;  sometimes  not  until  the 
second,  third,  or  even  fourth  day,  when  the  severe  pain  abates. 
In  these  cases,  the  friction  sound,  if  observed  at  all,  is  soon  fol- 
lowed by  feebleness  and  gradual  cessation  of  the  respiratory  mur- 
mur, by  bronchial  respiration,  egophony,  and  dullness  or  percus- 
sion. Should  the  progress  of  the  disease  be  now  arrested,  the 
general  symptoms  abate,  and  the  morbid  sounds  gradually  give 
way  to  the  healthy,  as  the  fluid  producing  them  is  absorbed. 


236  THORACIC    DISEASES. 

The  friction  sound  is  sometimes  heard  for  a  brief  period  after 
absorption  has  taken  place,  and  before  union  between  the  opposite 
surfaces  has  been  effected.  The  disease  is  usually  cured  in  five 
or  seven  days. 

"  But,  instead  of  the  favorable  turn  at  the  period  above  alluded 
to,  there  is  often  a  continued  advance  of  the  disease  ;  the  effusion 
goes  on  increasing  :,egophony  ceases;  the  bronchial  respiration 
becomes  more  and  more  distant,  until  this  also  ceases,  or  is  but 
faintly  heard  ;  flatness  upon  percussion  prevails  to  a  greater  or 
less  extent  over  the  chest,  generally  varying  with  the  position  of 
the  patient;  the  dimensions  of  the  affected  side  of  the  chest  are 
sometimes  even  visibly  enlarged ;  and  the  healthy  vibratory 
movement  of  its  walls  in  speaking  is  much  lessened  or  quite  want- 
ing, as  may  be  ascertained  by  applying  the  hand  to  the  surface. 
The  pain  has  nearly  ceased,  and  the  fever  moderated,  but  the 
dyspnoea  is  often  great,  and  the  patient  is  unable  to  lie  upon  the 
sound  side.  The  disease,  in  this  form,  continues  for  a  variable 
period.  Sometimes  recovery  takes  place  in  two  or  three  weeks, 
sometimes  not  for  months ;  and  the  complaint  not  unfrequently 
assumes  the  chronic  form.  Should  it  terminate  favorably,  the 
fever,  cough,  and  dyspnoea  gradually  disappear,  the  dullness  on 
percussion  diminishes,  egophony  occasionally  returns  in  the  pro- 
gress of  the  absorption,  the  respiratory  murmur  is  again  heard,  the 
friction  sound  may  be  noticed  for  two  or  three  days  or  more,  and 
health  is  at  length  re-established.  The  clearness  on  percussion, 
and  the  healthy  respiratory  sound,  return  usually  first  in  the  upper 
part  of  the  chest  and  afterward  in  the  lower. 

"As  the  lung  has  not  been  sufficiently  long  compressed  to  have 
lost  its  expansibility,  it  is  generally  dilated  as  the  fluid  is  absorbed  ; 
but  sometimes,  either  from  its  own  altered  state,  or  because  bound 
down  by  false  membrane,  it  does  not  completely  resume  its  orig- 
inal dimensions,  and  a  degree  of  contraction  in  the  diseased  side 
of  the  chest  ensues,  which,  however,  generally  diminishes,  or  dis- 
appears with  time.  The  favorable  termination  is  often  attended 
or  preceded  by  certain  critical  affections,  as  urinary  sediment,  co- 
pious perspiration,  diarrhoea,  eruptive  affections  of  the  lips  and 
skin,  plegmonous  tumors,  and  rheumatic  pains.  After  convalesc- 
ence, the  patient  not  unfrequently 'complains  of  a  stitch  in  the 


PLEURKTIS.  237 

side  upon  taking  a  long  breath ;  and  sometimes  a  degree  of  cough, 
dyspnoea,  and  frequency  of  pulse  remains  for  a  considerable  time. 

"  When  acute  pleurisy  is  about  to  terminate  fatally,  which  very 
seldom  happens  in  the  uncomplicated  disease  if  well  treated,  the 
effusion  increases,  the  breathing  becomes  very  greatly  oppressed, 
the  countenance  assumes  a  pale  hue  and  anxious  expression,  the 
pulse  increases  in  frequency,  and  at  length  becomes  small  and 
feeble,  and  the  heart  ceases  to  beat,  in  consequence  of  the  imper- 
fect performance  of  the  respiratory  function.  In  the  advanced 
stages,  death  sometimes  results  from  a  gradual  failure  of  the  pow- 
ers of  the  system,  caused  by  the  irritation  of  the  diseased  struc- 
ture. In  double  pleurisy,  according  to  Andral,  a  fatal  issue  may 
take  place  from  the  mere  influence  of  the  inflamed  membrane, 
without  any  discoverable  amount  of  fluid  secretions."  [Wood's 
Practice  of  Medicine.] 

The  most  common  terminations  of  this  form  of  pleurisy  are,  1st 
by  resolution ;  2nd,  by  passing  into  a  chronic  state  ;  and  3d,  by 
fatal  asphyxia.  Resolution  may  be  complete,  the  effused  fluid 
and  false  membranes  being  absorbed,  cellular  adhesions  being  the 
only  traces  left  of  the  disease,  or  it  may  be  incomplete.  In  the 
latter  case,  the  fluid  is  absorbed,  but  the  false  membranes  remain, 
and  are  subject  to  various  pathological  changes. 

The  second  of  these  terminations  will  be  considered  under  the 
head  of  Chronic  Pleurisy.  Death  by  asphyxia  occurs  only  in  the 
most  severe  cases,  and  is  the  result  of  great  and  sudden  effusion. 
This  termination  is  more  frequent  in  pleurisy  than  in  pneumonia. 
It  is  very  rare,  in  the  acute  stage,  and  in  those  cases  not  compli- 
cated with  other  diseases.  It  more  often  occurs  in  the  chronic 
form  of  the  disease. 

PROGNOSIS. — In  primary  sthenic' pleuritis,  affecting  only  one 
lung,  there  is  seldom  much  danger,  if  treated  in  the  early  stages 
with  proper  remedies.  After  copiouseflusion  the  cure,  of  course, 
is  liable  to  become  protracted,  but  is  generally  effected,  in  uncom- 
plicated cases,  without  much  difficulty.  In  short,  the  mortality 
from  this  disease,  when  not  associated  with  others,  is  comparative- 
ly small.  According  to  the  report  of  the  City  Inspector  of  New 
York,  the  whole  number  of  deaths  from  pleuritis  during  three  sue- 


238 


THORACIC    DISEASES. 


cessive  years,  was  only  one  hundred  and  six,  while  during  the 
same  period  of  time,  the  deaths  from  pneumonitis,  were  two 
thousand  five  hundred  and  fifty-eight. 

TREATMENT. — In  laying  down  the  treatment  of  particular  dis- 
eases, I  will  endeavor  to  recommend  the  pursuit  of  that  course, 
which  to  me  and  to  my  medical  brethren,  seems  most  necessary 
and  effectual.  My  object  will  be  to  adapt  the  treatment  to  the 
different  stages  of  disease  and  to  its  various  forms  whether  sthenic 
or  asthenie;  changing  the  remedies  according  to  the  pathological 
changes  of  the  organs  affected. 

In  the  inflammatory  stage  of  sthenic  pleuritis,  when  the  pain 
in  the  side  is  severe,  the  skin  dry  and  hot,  the  pulse  fall  and  tense, 
a  decided  impression  should  speedily  be  made  upon  the  circula- 
tion of  the  blood.  To  accomplish  this,  and  to  relSx  the  muscu- 
lar system  and  to  favor  cutaneous  secretion,  the  vapor  bath,  is  an 
efficient  means  of  cure.  It  should  be  continued  until  a  degree  of 
prostration  bordering  on  syncope  is  produced. 

When  the  bath  cannot  be  used,  sinapisms,  stimulating  lini- 
ments, warm  fomentations  should  be  substituted.  And,  in  cases 
where  the  bath  is  applied,  the  latter  means  should  also  be  used  as 
valuable  accessory  treatment. 

The  contact  of  air, — a  thing  always  to  be  avoided  in  pleurisy, 
— is  prevented  by  these  external  applications.  For  the  same  pur- 
pose, and  to  supersede  entirely  the  use  of  other  external  means, 
there  is  used  in  Bellevue  Hospital,  New  York,  a  jacket  or  waist- 
coat of  oiled  silk.  This,  when  it  can  be  applied,  has  many  ad- 
vantages, over  other  applications.  It  is  less  troublesome  to  the 
patient,  more  neat,  and  permits  a  change  of  position,  without  be- 
smearing or  wetting  the  bed  clothes. 

The  internal  remedy  upon  which  the  most  reliance  should  be 
placed,  is  lobelia.  I  prefer  the  extract.  Ordinarily  this  should  at 
first  be  given  in  small  and  increasing  doses,  in  order  that  the  re- 
laxing and  sedative  effect  may  precede  the  production  of  free 
emesis.  Cases  may  occur  in  the  treatment  of  which  the  remedy 
should  be  administered  in  common  emetic  doses.  My  manner  of 
giving  it,  is  to  administer  an  extract  pill,  containing  from  gr. 
ii,  to  gr.  v,  once  in  half  an  hour,  and  to  continue  so  to  do,. 


PLEURITIS.  239 

Until  perspiration,  relaxation  and  free  emesis  are  the  result.  The 
degree  to  which  the  remedy  should  be  carried  in  its  application, 
must  depend  upon  the  violence  of  the  disease,  and  the  difficulty 
of  obtaining  relief. 

The  pain  may  be  removed,  in  part,  at  least,  by  applying  tight 
around  the  thorax,  a  bandage.  The  object  of  this  is  to  stop  the 
friction  of  the  lung  on  the  parietes  of  the  chest,  and  to  throw  the 
labor  of  respiration  mostly  upon  the  abdominal  muscles.  After 
the  stomach  has  been  thoroughly  evacuated,  the  patient  should 
have  an  interval  of  rest,  and  should  take  freely  of  gum  acacia 
water  in  order  to  sustain  the  system. 

After  the  stomach  has  become  quiet,  in  case  a  cathartic  is  indi- 
cated, one  should  be  administered.  The  following  in  most  cases 
is  as  serviceable  as  any.  The  proportions  of  the  articles  in  the 
formula  should  be  varied  according  to  the  exigencies  of  the  case  : — * 

R         Leptandrias*  gr.  v., 

Or  leptandriBB  virginicas  5  i., 

Podophyllia3  gr.  i.  ad  gr.  ii. 

Misce. 
To  be  taken  in  sirup  or  molasses. 

°  In  using  the  termination  CK  of  the  genitive  singular  of  Latin  nouns  in  the  first 
declension,  I  pursue  what  seems  to  me  the  most  reasonable  course.  Nearly  all  the 
names  of  concentrated  remedies  terminate  in  ine  or  in.  If  they  be  considered  as 
Latin  nouns  of  the  third  declension,  terminating  in  the  nominative  singular  in  ine, 
then,  like  sedile,  their  genitive  must  end  in  is.  For  example  podophylline  (nomina- 
tive), podophyllinif  (genitive).  Against  this  method  of  termination,  though,  so 
far  as  1  can  see  perfectly  proper,  these  objections  may  be  brought : — In  the  first 
place  it  makes  the  words  longer  : — In  the  second  place,  it  does  not  conform  to  the 
termination  of  other  names  of  medicines.  Thus,  from  quinine,  we  have  quinia  in 
the  nominative,  and  consequently  quinicc  in  the  genitive,  the  termination  of  which 
case  is  the  proper  one  to  be  used  in  writing  Latin  recipes.  The  same  may  be  said 
of  morphine  and  strychnine.  In  these  examples  the  last  n,  with  the  last  vowel,  is  eli- 
ded, and  the  letter  a  forming  the  correct  termination  of  Latin  nouns  of  the  first 
declension,  is  substituted  for  the  last  n  in  these  words.  What  objection,  then,  can 
there  be  to  the  adoption  of  the  same  rule  in  forming  terminations  to  the  concentra- 
ted remedies  ?  I  can  see  none,  except  it  be  this ; — that  in  three  words,  leptandria, 
sanguinaria,  lobelia,  meaning,  these  articles  in  a  crude  state,  these  are  the  same 
terminations,  as  would  be  found  appended  to  the  names  of  those  articles  in  a  con- 
centrated state,  in  case  the  above  rule  were  adopted.  Thus,  leptandrine,  dropping 
the  termination  ne,  and  adding  a  becomes  leptandria,  the  name  of  the  crude  article. 
This,  I  believe,  is  the  only  reason  which  at  first  might  seem  to  militate,  against  the 


240  THORACIC    DISEASES. 

After  the  operation  of  the  cathartic,  in  order  to  produce  diapho-* 
resis,  and  lessen  the  inflammation,  administer  once  in  four  hours, 
a  pill  containing  of  the  extract  of  lobelia,  from  gr.  i.  to  gr.  iv.  al- 
ternately with  the  following  powder  : — - 

ft         Asclepias  gr.  xv., 

Or  asclepiadis  tuberoses  9ii-> 

Pulveris  camphoras  gr.  xii., 

Pulveris  opii  gr.  iii., 

Pulveris  ipecacuanhas  gr.  vi., 

Potasses  sulphatis  9j. 
Misce. 

Dose — from  gr.  v.  to  gr.  x.  once  in  four  hours  alternately  with 
the  pills. 

If  the  above  treatment,  after  twenty-four  or  forty-eight  hours, 
fails  to  give  relief — which  it  will  seldom  fail  to  do — inflammatory 
symptoms  still  continuing,  the  whole  chest  should  be  fomented 
with  flannels,  wet  in  water  so  hot  as  to  almost  blister  the  surface. 
This  is  usually  very  effectual  in  removing  the  pain.  The  ex- 
tremities may  with  a  good  effect,  be  bathed  in  some  cooling  li- 
quids, either  water  alone,  or  weak  ley  water,  or  alcohol  and  water. 

Some  prefer  cold  water  applied  directly  to  the  affected  side. 
Whether  or  not  this  is  belter  than  warm  water,  or  fomentations, 
is  not  as  yet  fully  decided.  To  me-  it  seems  too  dangerous  an 
application  to  be  left  to  the  discretion  of  a  nurse.  In  the  purely 
sthenic  variety  of  the  disease,  its  effect  is  probably  best — But  in 
asthenic  cases,  it  would  be  liable  to  produce  a  permanent  chill, 
and  thus  become  a  source  of  new  difficulty  in  th'e  cure  of  the 
patient. 

adoption  of  the  above  rule.     A  little  consideration,  however,  Trill  remove  this  ob- 
jection. 

Whenever  the  crude  article  is  meant,  in  writing  the  Latin  formulae,  by  append- 
ing to  the  generic  terms,  the  specific  names  of  those  three  articles^  a  clear  distinc- 
tion can  be  made  between  the  crude  and  concentrated  remedies.  No  such  difficulty, 
in  the  great  majority  of  cases,  occurs.  Out  of  twenty-six  articles,  there  are  only 
three  in  which  there  is  any  need,  in  order  to  perspicuity,  of  using  the  specific  name. 
I  shall,  therefore,  in  all  formulae,  in  this  work,  adopt  the  above  rule ;  and,  in 
order  that  there  may  be  symmetry  and  uniformity  in  the  nomenclature  of  concen- 
trated remedies,  I  would  recommend  others,  in  case  the  above  suggestions  shall 
seem  proper  and  useful,  "  To  go  and  do  likewise." 


PLEURITIS.  241 

In  case  these  means  do  not  have  the  desired  effect,  as  a  "  der- 
nier resort"  an  enema  of  lobelia  retiined  until  emesis  is  produced, 
and  relaxation  is  complete,  will,  in  persons  of  strong  constitutions, 
and  of  plethoric  habit,  be  the  most  effectual  means  of  subduing 
the  inflammation.  "  The  application  to  the  side,"  says  Dr.  J.  A. 
Andrews,  "of  a  poultice  composed  of  equal  parts  of  podophyllum 
and  ictodes  foetida  will  in  most  cases  produce  sufficient  counter 
irritation  to  effect  the  desired  object." 

When  copious  effusion  is  evinced  by  the  physical  signs,  and 
the  object  is  to  excite  the  action  of  the  absorbents,  a  blister  pro- 
duced by  an  adhesive  plaster,  sprinkled  over  with  podophyllin, 
will  be  useful.  By  high  authority,  which  to  be  sure  is  not  always 
to  be  obeyed,  unless  that  authority  be  clad  in  the  garb  of  reason 
and  science,  the  common  mode  of  vesicating  in  the  stage  when 
effusion  is  copious,  is  highly  recommended.  Concerning  the  pro- 
priety of  this,  the  scientific  practitioner  should  exercise  his  judg- 
ment, rather  than  yield  to  the  bias  of  preconceived  opinions. 

The  above  course  of  treatment  is  the  one  most  frequently 
adopted  in  the  inflammatory  stages  by  eclectic  practitioners.  Dif- 
ferent physicians  have  different  methods  of  applying  remedies. 
Dr.  J.  A.  Andrews — who,  during  nearly  twenty  years  of  practice 
has  had  almost  universal  success  in  the  cure  of  this  disease — pur- 
sues the  following  course  of  medication.  *  At  first  he  adminis- 
ters an  emetic  compounded  after  this  formula  : — 

R         Asclepiadis  3  ii., 

Lobelise  inflatag  5vi., 

Capsici  E)i. 

Mi  see. 

Dose, — gr.  xxx.,  once  in  fifteen  minutes,  until  free  emesis  en- 
sues. 

After  the  effect  of  the  emetic  has  subsided,  he. then  adminis- 
ters, once  in  three  hours,  a  powder  of  the  following  compound: — 

ft         Asclepiadis  5v., 

Lobeliae  inflataB  5  ii., 

Ictodis  fo3tida3  3  i., 

Capsici  9  i. 

31 


242 


THORACIC    DISEASES. 


To  be  administered  in  infusion,  and  in  doses  sufficiently  large 
to  produce  diaphoresis  and  relaxation. 

In  case  an  expectorant  is  needed,  he  uses  the  following : — • 

Senegas  pulveris  gr.  x., 

Lobelise  inflatse  pulveris  gr.  v., 

CorallorhizEe  odontorhizae  pulveris  gr.  v. 
Misce. 

This  should  be  administered  as  often  as  its  effects  are  desirable. 
On  the  third  day  he  usually  prescribes  a  mild  cathartic,  moving 
the  bowels,  if  necessary,  before  that  day  by  enemas. 

Whenever  the  common  nervines,  such  as  cypripedium,  scutell- 
aria,  fail  to  produce  the  necessary  repose  of  the  patient,  he 
prescribes  as  a  "  dernier  resort  "  an  opiate  : — 

R:         Asclepias  3  i., 

Potassas  bitartratis  5  i., 

Opii  sss., 

Ari  triphylli  5i. 

Misce. 

Dose, — from  gr.  v.  to  gr.  vii.,  as  occasion  requires. 

All  of  these  anti-inflammatory  means  should  be  repeated  as  the 
case  demands. 

In  the  second  stage  of  simple  sthenic  pleuritis,  or  that  of  effu- 
sion, diuretics  are  often  of  great  value.  In  case  the  quantity  of 
effused  fluid  is  great  and  the  patient  sufficiently  strong,  hydra- 
gogue  cathartics,  are  also  effectual  means  of  exciting  absorption. 
The  articles  most  useful  for  this  purpose  are  podophyllin,  jalap, 
and  cream  of  tartar. 

When  catarrhal  symptoms  coexist  with  those  of  pleurisy,  sene- 
ga is  useful.  Diuretics  are  also  valuable  to  fulfil  similar  indica- 
tions. Among  the  best  are  galium  aperine,  eupatorium  purpureum, 
aralia  hispida,  the  seed  of  arctiurn  lappa.  These  latter  remedies 
are  much  more  safe  than  others.  Of  the  aralia  hispida,  Dr.  H. 
Jacobs,  an  experienced  and  successful  practitioner,  makes  frequent 
use  for  the  purpose  of  producing  the  absorption  of  serous  effusion. 

In  the  treatment  of  pleuritis,  reference  must  always  be  had  to 
the  state  of  the  system,  and  when  this  is  asthenic  the  relaxing 


PLEURITIS.  243 

and  sedative  means  must  be  employed  with  more  caution.  In 
bilious  pleuritis,  cholagogues  should  be  administered  early  in  the 
disease.  If  there  are  typhoid  symptoms,  or  if  the  disease  assumes 
an  intermittent  form,  quinine  should  be  freely  given.  When  pleu- 
ritis is  complicated  with  tubercular  disease,  care  should  be  taken 
that  the  relaxing  remedies  are  not  carried  too  far,  lest  their  effects 
by  producing  debility,  tend  to  excite  the  further  deposition  of  tu- 
bercles. 

The  diet  in  acute  pleuritis  should  be  very  low,  consisting  in  the 
early  stages  chiefly  of  mucilaginous  or  farinaceous  liquids.  Gum 
acacia  water  is  almost  the  only  food  allowed  in  the  Hospitals  in 
Paris.  This,  by  French  physicians,  is  considered  perfectly  safe , 
for  diet,  and  a  very  useful  medicament,  even  when  given  in  large 
quantities.  Refreshing  acidulated  drinks  may  be  freely  allowed. 
Lemon  juice,  added  to  acacia  water,  or  to  an  infusion  of  flax-seed, 
makes  an  excellent  compound.  Sometimes,  the  addition  to  the 
above  drink  of  licorice  is  useful.  The  patient  should  avoid  mo- 
tion and  speaking,  or  coughing  as  much  as  possible.  The  shoul- 
ders and  chest  should  be  somewhat  elevated  with  pillows.  The 
temperature  of  the  room  should  be  uniform,  both  day  and  night. 
In  making  any  physical  exploration,  the  chest  should  not  be  un- 
necessarily exposed  to  the  contact  of  air. 

"  When  we  find  the  pleuritis  nearly  well,"  says  Dr.  Gerhard, 
"  but  the  patient  still  complaining  of  some  dyspnoea,  or  a  little 
feverishness,  and  we  discover  on  examination  that  a  portion  of 
the  liquid  remains  unabsorbed,  nothing  is  so  efficacious  as  a  jour- 
ney, with  its  necessary  consequence,  change  of  air.  Although 
the  sea-air  is  not  always  adapted  to  pectoral  diseases,  it  is  often  of 
decided  advantage  in  chronic  pleuritis,  especially  if  combined  with 
a  voyage.  This  is  generally  the  surest  means  of  dissipating  the 
remains  of  the  disease,  and  insuring  a  restoration  to  entire  health. 
Of  course,  the  usual  hygienic  precautions  as  to  dress  should  be 
attended  to." 


244  THORACIC    DISEASES. 

SECTION  II. 
ASTHENIC   PLETJRITIS. 

PATHOLOGY. — This  form  of  pleuritis  is  usually  met  with  in  per- 
sons who  have  been  debilitated  by  previous  acute  or  chronic  dis- 
eases. Most  frequently  it  occurs  in  the  intemperate,  or  during  con- 
valescence from  febrile  diseases  of  a  typhoid  type,  from  exanthe- 
matous  and  puerperal  fevers,  from  erysipelas  ;  or  it  arises  from  or- 
ganic changes  in  the  kidneys,  from  phlebitis  and  diffusive  inflam- 
mation resulting  in  the  formation  of  abcesses. 

With  acute  or  painful  local  symptoms,  this  form  of  the  disease 
is  seldom  attended.  The  disease  is,  for  the  most  part,  latent,  ef- 
fusion often  existing  long  before  the  disease  is  detected.  Rarely 
a  primary  affection,  it  is  most  often  associated  with  some  other 
disease,  or  with  some  structural  change.  Its  presence  is  indicated 
at  first,  by  shortness  of  respiration,  the  position  of  the  patient,  and 
the  sinking  of  the  powers  of  life,  more  than  by  any  severe  local 
distress.  The  diagnosis,  prognosis  and  treatment  of  this  variety 
of  pleuritis,  are  so  similar  to  those  of  the  chronic  form  of  the  dis- 
ease, that  no  separate  description  is  necessary. 

SECTION  III. 
CHRONIC  PLEURITIS. 

Pleurisy  varies  greatly  both  in  severity  and  in  duration.  It 
may  be  acute,  in  respect  to  the  degree  of  suffering,  and  the  rap- 
idity of  its  progress  ;  it  may  be  latent  in  its  character  and  slow  in 
the  progress  of  the  successive  changes  attending  and  consequent 
upon  it.  Between  these  extremes,  the  intermediate  grades  of 
morbid  action  are  almost  innumerable.  The  term  chronic,  then, 
in  respect  to  pleuritis,  seems  to  be  more  of  a  conventional  term, 
than  when  applied  to  most  other  diseases.  In  pleuritis  the  tran- 
sition of  the  acid;  to  the  chronic  state  is  so  indefinite,  and  the 
symptoms  of  the  recent  disease  sometimes  have  so  little  of  an 
acute  character,  while  that  of  a  long  duration  occasionally  rnani- 


PLEURITIS.  245 

fests  so  much  greater  an  intensity  of  irritation,  that  the  terms 
acute  and  chronic  would  seem  to  be  less  applicable  to  pleuritis 
than  to  other  diseases.  This  difficulty  arises  from  the  anatomical 
relations  of  the  pleura.  Being  a  shut  sac,  its  acute  inflammation 
is  liable  to  be  made  chronic  by  the  retention  of  inflammatory 
products.  And  the  chronic  is  liable  to  be  changed  into  the  acute 
by  the  irritation  of  effused  fluids. 

But,  notwithstanding  these  difficulties,  there  seems  to  be  no 
impropriety  in  ascribing  to  the  disease,  when  highly  inflammatory 
and  until  the  inflammatory  symptoms  seem  to  arrive  at  an  acme, 
the  term  acute.  If  after  that  period,  lingering  fever  continues, 
evidently  excited  by  the  products  of  previous  inflammatory  ac- 
tion, then  the  term  chronic  may,  with  as  much  propriety,  be  ap- 
plied to  the  disease  after,  as  the  acute  to  the  disease  before  the 
acme.  In  some  cases,  however,  such  an  acme  never  seems  to  exist; 
and,  to  these  the  name  sub  acute  may  with  propriety  be  applied. 

PATHOLOGY. — The  anatomical  appearances  caused  by  chronic 
pleuritis  are  very  similar  to  those  of  the  acute  form  of  the  disease. 
Of  course,  the  influence  of  time  would  tend  to  produce  certain 
modifications.  In  general  we  find  the  membranes  thicker,  often 
composed  of  several  adherent  layers,  the  earliest  deposits  being 
harder  than  those  subsequently  formed.  The  character  of  the 
liquid,  too,  is  subject  to  various  changes  in  the  onward  progress 
of  the  disease.  It  is  less  limpid,  more  prone  to  become  turbid 
with  flocculi  of  a  fibrinous  character.  In  some  cases  it  even  ap- 
pears in  consistence  like  jelly.  The  quantity  is  greater,  and  con- 
sequently the  displacement  of  adjacent  viscera  is  much  more  ap- 
parent. The  lung  by  continued  compression  is  altered  in  its  ap- 
pearance, and  often  becomes  wholly  destitute  of  its  normal  crepi- 
tation on  pressure.  Here  and  there  adhesions  are  often  formed, 
between  which  in  some  cases,  little  sacs  of  fluid  are  enclosed. 

Under  the  best  treatment,  the  disease,  when  uncomplicated, 
will  generally  advance  to  a  favorable  termination.  But  it  often  is 
the  case,  that  the  morbid  products  cannot  be  absorbed,  and,  con- 
sequently, they  remain  and  pass  through  a  series  of  pathological 
changes,  sometimes  ending  in  gangrene.  Cartilaginous  laminae, 


246  THORACIC    DISEASES. 

bony  plates,  abscesses,  tubercles  and  hemorrhagic  effusions,  are 
among  the  successive  steps  in  the  progress  of  chronic  pleuritis. 

"  Sometimes,"  says  Dr.  Wood,  "  the  walls  of  the  chest  are 
forced  inward  contrary  to  their  elasticity,  so  that,  when  a  puncture 
is  made  from  without,  the  air  rushes  in  to  supply  the  vacuity  pro- 
duced by  their  resilience.  In  some  instances  secretion  goes  on  as 
rapidly  as  absorption,  and  the  liquid  accumulation  remains  for  a 
great  length  of  time.  This  is  especially  the  case  in  empyema, 
or  collection  of  pus  in  the  cavity  of  the  pleura  •  sometimes  the  pus 
makes  its  way  into  the  substance  of  the  lung,  arid  a  fistulous 
communication  is  formed  between  the  bronchi  and  the  pleural 
cavity,  through  which  pus  is  discharged  and  air  admitted. 

"  In  other  instances  the  liquid  takes  an  external  direction,  and 
by  means  of  ulceration  escapes  into  the  cellular  tissue  without 
the  chest,  and,  traveling  occasionally  for  a  considerable  distance, 
produces  subcutaneous  abscesses  in  various  parts  of  the  chest, 
which  ultimately  open,  unless  life  is  previously  worn  out.  In 
thus  traveling,  the  pus  has  been  known  to  occasion  caries  of 
the  ribs  and  vertebras,  sometimes  the  purulent  collection  is  found 
to  be  connected  with  a  tuberculous  vomica." 

It  is  sometimes  difficult  to  determine  the  causes  which  change 
ordinary  acute  pleuritis  into  the  chronic  form.  Evidently  in 
many  cases,  too  much  depletion,  the  too  free  use  of  mercury  and 
other  articles  making  up  the  antiphlogistic  regimen,  tend  to  the 
production  of  chronic  pleuritis.  Often,  when  a  case  seems  to  be 
cured  by  such  means,  the  impoverished  state  of  the  blood,  caused 
by  the  use  of  the  lancet,  thus  rendering  the  system  more  liable 
to  be  affected  by  low  grades  of  inflammation,  develops  a  new  and 
unwelcome  train  of  symptoms  admonishing  the  physician  that  the 
supposed  cure,  was  after  all,  delusive. 

Dr.  Gallup,  defining  chronic  rheumatism,  says  that  it  is  acute 
rheumatism  half  cured.  So  it  may  with  equal  propriety  be  said, 
that  chronic  pleuritis  is  the  acute  variety  half  cured. 

DIAGNOSIS. — The  general  inflammatory  symptoms  of  acute  pleu- 
ritis may  gradually  disappear,  but,  unless  the  morbid  products  of 
the  diseased  action  are  removed  from  the  pleural  sac,  the  fever 
will  recur  and  change  its  type,  now  very  closely  resembling 


PLEtfRlTIS.  247 

hectic,  now  becoming  identical  with  it.  This  recurring  fever  is 
one  of  the  most  troublesome  and  alarming  symptoms  of  chronic 
pleuritis;  for  in  other  respects  the  patient  does  not  suffer  in  a 
manner  proportionate  to  the  extent  or  the  duration  of  the  effusion. 
Dr.  Gerhard  observes,  "  I  once  saw  a  patient  who  had  performed 
the  full  duties  of  a  sailor,  going  aloft,  with  an  enormous  pleuritic 
effusion.  When  he  returned  from  sea,  it  amounted  to  two  or 
three  gallons.  This  is  an  exceptional  case  ;  but  it  is  very  com- 
mon to  find  patients  who  can  perform  many  laborious  occupations 
without  much  inconvenience.  This  is  generally  the  case  if  the 
dyspnoea  is  not  severe ;  and  we  find  that  some  patients  complain 
of  little  difficulty  of  breathing  with  an  extent  of  pectoral  disease 
which  will  give  rise  to  great  distress  in  other  individuals.  The 
symptoms  which  so  frequently  characterize  chronic  organic  dis- 
eases, are  extremely  variable  in  this  variety  of  pleurisy.  These 
are  emaciation,  loss  of  the  firmness  of  the  muscles,  harshness  and 
dryness  of  the  skin,  and  slight  oedema  of  the  legs.  Sometimes 
they  are  nearly  as  well  marked  as  in  tuberculous  disease  of  the 
lungs  ; — in  other  cases  they  are  very  slight ;  hence,  they  consti- 
tute a  diagnostic  sign  of  the  disease ;  and,  if  we  find  them  well 
characterized,  we  will  do  right  to  regard  the  case  as  one,  probably, 
complicated  with  tubercles.  If  our  impression  be  erroneous,  we 
will  soon  rectify  it,  as  the  symptoms  will  gradually  become  more 
decided  in  the  latter  case,  and  slowly  disappear  if  the  pleurisy  be 
followed  by  recovery." 

The  diagnosis  of  chronic  pleuritis  without  the  aid  of  the  phys- 
ical signs,  is  often  very  difficult.  Its  general  symptoms  simulate 
those  of  phthisis.  But  the  physical  signs  are  far  more  reliable. 
When  these  are  present  there  is  no  difficulty  in  ascertaining  the 
true  character  of  the  disease.  If  it  is  complicated  with  tubercu- 
lous deposition,  the  case  should  be  regarded  with  much  anxiety; 
for  the  diagnosis  then  becomes  much  more  obscure,  and  the  prog- 
nosis more  unfavorable. 

PROGNOSIS. — In  this  variety  of  pleuritis,  when  attended  with 
copious  effusion,  the  prognosis  is  doubtful.  The  liquid  consisting 
mainly  of  pus,  causes  irritation,  sometimes  so  severe  as  to  produce 
marasmus,  and  to  deprive  the  system  of  all  that  recuperative 


THORACIC    DISEASES. 

power  ever  necessary  in  the  progress  of  recovery.  Sometimes  it 
proves  fatal  in  .consequence  of  the  obstruction  to  respiration  ; 
sometimes  by  the  occurrence  of  metastatic  abscesses  in  parenchy- 
matous  organs.  This  latter  result,  however,  is  not  very  common. 

TREATMENT. — The  treatment  of  chronic  pleuritis  differs  from 
that  of  the  sthenic  character,  less  in  the  kind  of  remedies  used, 
than  in  the  manner  of  their  application.  Whatever  means  are 
applied  should  be  such  as  tend  to  prevent  effusion  and  promote 
absorption.  For  these  purposes  gentle  emetics,  followed  by  the 
use  of  vegetable  tonics,  are  very  serviceable.  Of  the  utility  of 
occasional  emetics  of  lobelia  in  chronic  pleuritis,  there  is  much 
evidence.  Their  operation,  in  my  opinion,  is  more  sure  than  any 
other  means,  to  prevent  effusion  and  promote  absorption,  and  to 
prepare  the  digestive  organs,  for  the  successful  administration  of 
tonics.  Those  who  are  anasmic  seldom  bear  well  the  effects  of 
emetics,  especially  of  thorough  ones.  But  those  whose  digestive 
organs  are  inactive,  accompanied  with  febrile  excitement,  with 
dry  and  hot  skin,  and  headache,  with  derangetnent  in  the  circula- 
tion of  the  blood,  will  receive  benefit  from  their  occasional  use.  In 
connection  with  them,~  the  vapor  bath,  or  in  cases  where  proper 
reaction  is  sure  to  result,  the  pack  sheet,  may  often  successfully 
be  applied. 

Counter  irritation  is  useful  in  this  variety  of  the  disease.  For 
this  purpose  podophyllum  or  podophyllin  sprinkled  upon  the  sur- 
face of  an  adhesive  plaster  and  applied  to  the  side,  will,  in  a  short 
time,  produce  free  suppuration.  The  same  and  perhaps  a  better 
effect  may  be  derived  from  the  use  of  Dr.  Hill's  irritating  plaster. 
Senega  and  squill  may  be  employed  with  benefit.  To  promote 
absorption,  the  iodide  of  potassium  has  been  highly  praised. 
When  hectic  symptoms  appear,  they  should  be  combatted  with 
tonics.  The  infusion  or  the  sirup  of  wild  cherry,  I  have  found 
more  efficacious  than  many  other  tonics.  I  prescribe  this,  in 
connection  with  the  sirup  of  the  iodide  of  iron.  One  ounce  of  the 
latter,  added  to  one  pint  of  the  sirup  of  the  former  article,  makes 
a  good  compound. 

If  there  is  great  debility  sulphate  of  quinine,  salicine  and  hy- 
drastine  should,  either  separately  or  in  combination,  be  adminis- 


PLEURITIS.  249 

lered.  To  allay  cough  and  produce  sleep  in  those  cases  attended 
with  much  fever,  I  am  accustomed  to  use.  in  connection  with 
other  nervines,  the  following  preparation  : — 

R         Extract!  lobelias  gr.  ij  ad  gr.  iv., 

Morphia}  acetatis  gr.  1-8  ad  gr.  1-4. 

Misce. 

Administer  at  bed  time.  This  usually  produces  diaphoresis, 
allays  febrile  symptoms,  and,  by  promoting  expectoration  and 
quieting  nervous  excitability,  relieves  the  cough. 

If  there  is  a  tendency  to  tubercular  disease  with  considerable 
debility,  not  attended  with  much  fever,  I  direct  the  patient  to  use 
for  diet,  eggs,  oysters, beef,  with  other  nutritious  and  easily  diges- 
tible articles,  and  to  take  as  a  beverage  some  pure  wine,  in 
quantities  not  large  enough  to  excite  febrile  action,  and  for  medi- 
cine to  take  some  tonic  sirup  containing  iodine  in  some  of  its 
forms. 

In  very  old  pleurisy,  tonics  are  sometimes  necessary,  especially 
when  the  suppuration  is  abundant.  In  such  cases  the  chalybeate 
preparations  are  recommended  by  Dr.  Gerhard.  With  these  and 
vegetable  tonics,  acutancous  tonic  and  alterative  may  with  benefit 
be  combined  ;  such  as  a  stimulating  bath,  especially  the  sulpur 
and  salt  water  bath.  These  are  usually  taken  at  their  natural 
sources,  by  resorting  to  sulphur  springs  or  to  sea  bathing.  When 
the  artificial  baths  are  used  they  should  be  warm.  Of  cold  sea 
bathing,  and  the  cold  sulphur  bath  for  mere  debility,  after  the  sub- 
sidence of  inflammation,  Dr.  Gerhard  says,  "that  they  are  seldom 
appropriate,  and  that  if  used  at  all  some  caution  should  be  ob- 
served in  their  management." 

"In  chronic  pleurisy"  he  continues,  "  it  sometimes  becomes  a 
question  whether  the  operation  of  paracentesis  should  be  per- 
formed. This  is,  as  is  well  known,  one  of  the  most  simple  oper- 
ations in  surgery,  and  no  one  can  meet  with  the  least  difficulty  in 
performing  it, — but  at  the  same  time,  it  is  often  very  serious  in  its 
consequences.  There  is  a  rule  in  surgery  which  is  here  strictly 
applicable  ;  that  is,  that  the  exposure  of  a  large  suppurating  cavi- 
ty to  the  air,  necessarily  excites  hectic  fever,  and  sometimes  fa- 
vors the  development  of  secondary  abscesses.  The  chances  of 
32 


250  THORACIC    DISEASES. 

recovery  are  not,  therefore,  on  the  whole  increased  by  the  opera- 
tion, and  it  is  one  which  we  should  not  perform,  unless  it  be  to 
relieve  excessive  dyspnoea,  which  may  in  itself  be  severe  enough 
to  threaten  life." 

Concerning  the  safety  and  utility  of  this  operation,  authors  ad- 
vance different  opinions.  To  prove  that  many  lives  have  been 
saved  by  the  spontaneous,  or  by  the  artificial  discharge  of  the 
purulent  collection,  much  evidence  can  be  advanced. 

'•  In  my  own  mind,"  says  'Dr.  Swett,  "  there  is  no  doubt  that 
in  many  cases  in  which  the  discharge  of  pus  occurred  at  a  late 
period,  and  in  which  death  finally  ensued,  recovery  would  have 
taken  place,  had  the  discharge  of  the  purulent  secretion  taken 
place  at  an  earlier  period  in  the  disease. 

"  My  decided  impression  is,  that  in  all  cases,  after  proper  reme- 
dies have  been  tried  in  vain,  the  operation  for  empyema  should 
be  resorted  to,  and,  if  possible,  before  the  vital  powers  are  much 
exhausted.  Because,  notwithstanding  the  great  and  immediate 
relief  experienced  from  the  discharge  of  the  pus,  still,  a  great  deal 
of  it  remains  to  tax  the  powers  of  life.  A  more  or  less  copious 
purulent  secretion  continues  often  for  a  long  time. 

"  There  are  three  classes  of  cases,  in  which  the  question  as  to 
the  propriety  of  performing  the  operation  may  be  discussed. 
First,  there  are  the  cases  in  which  the  side  is  much  dilated,  the 
intercostal  spaces  bulging  and  fluctuating,  and  in  which  pointing 
even  has  occurred.  These  are  the  cases  in  which  the  operation 
has  most  generally  been  performed.  Before  the  discovery  of  aus- 
cultation, these  were  the  only  cases  in  which  it  could  be  performed 
with  propriety,  for  in  such  cases  only  could  the  existence  of  mat- 
ter in  the  pleural  sac  be  ascertained  with  any  degree  of  certainty. 
Many  cases  in  which  the  operation  is  performed  under  such  cir- 
cumstances, recover,  but  death  is  by  no  means  of  rare  occurrence. 
The  patient  is  relieved,  often  very  much  relieved  at  first,  but  he 
soon  dies  of  exhaustion. 

"Again,  there  is  a  class  of  cases  in  which  the  disease,  having 
resisted  all  treatment,  presents  a  different  condition  of  things. 
The  affected  side  is  not  at  all  dilated,  or  but  slightly  so ;  the  in- 
tercostal spaces  may  be  a  little  dilated  or  not,  but  there  is  no  fluc- 
tuation, and  especially  no  pointing.  Shall  an  operation  be  ad- 


PLEURITIS.  251 

vised  in  this  case  ?  I  think  so,  and  that  the  chances  of  success 
will  be  greater  than  in  the  first  class  of  cases.  There  is  one 
thing  that  you  must  endeavor  to  be  certain  about — that  is,  the  ac- 
tual existence  of  pus  in  the  chest.  The  history  of  the  case,  the 
progress  of  the  physical  signs  must  be  your  guide,  and  your  judg- 
ment must  guard  you  against  a  hasty  decision. 

"  Finally,  there  is  another  class  of  cases,  in  which  the  effused 
pus  has  been  absorbed  partially,  and  in  which  the  dilatation  of 
the  affected  side,  if  it  had  existed,  has  given  place  to  even  a  par- 
tial contraction.  Yet  the  existence  of  great  dullness,  and  the  ab- 
sence of  a  respiratory  murmur  over  the  lower  portion  of  the  lung, 
the  existence  of  hectic  fever,  and  of  other  symptoms,  must  lead 
to  the  belief  that  the  pus  is  still  there,  and  that  it  refuses  to  be 
absorbed.  The  cause  of  thfs  cessation  of  the  absorption  is  prob- 
ably the  compressed  state  of  the  lung,  which  refuses  to  expand. 
What  shall  be  done  in  this  case  ?  Open  the  chest  ?  I  confess  I 
have  never  seen  the  operation  performed  under  these  circumstan- 
ces, but  I  have  examined  fatal  cases  in  which  I  wished  it  had 
been  performed. 

"  Another  question  presents  itself  in  these  cases.  What  is  the 
condition  of  the  lungs  ?  What  is  the  condition  of  other  organs  ? 
It  is  certainly  desirable  to  know  that  the  lungs  were  probably 
healthy  before  the  attack,  and  that  no  evidence  exists  of  any  sub- 
sequent disease.  Suppose,  after  examining  the  chest,  we  suspect 
that  an  abscess  is  forming  in  the  lung.  Shall  this  make  you  hes- 
itate ?  Shall  you  wait  and  see  if  nature  will  not  open  a  commu- 
nication with  a  bronchus,  and  thus  discharge  the  pus  ?  We  may 
wait  in  vain  for  this  result,  and  even  if  it  should,  in  time  occur, 
it  is  a  far  less  agreeable  and  thorough  mode  of  evacuating  the 
chest  than  the  operation  of  paracentesis.  Suppose  we  have  rea- 
son to  fear  that  the  patient  may  be  tuberculous,  should  that  deter 
us?  I  think  not.  Would  we  not  open  an  abscess  anywhere  else 
in  a  tuberculous  patient  ?  Would  the  discharge  of  pus  exhaust 
him  ?  I  think  not.  It  would  relieve  him,  and  thus  prolong  his 
existence. 

"Even  in  cases  in  which  a  softened  tubercle  has  ruptured  into 
the  pleural  cavity,  and  a  bronchial  communication  has  been,  at 
the  same  time  established,  constituting  what  is  called  hydro-pneu- 


252  THORACIC    DISEASES. 

mothorax,  should  this  operation  even  then  be  performed  ?  I  have 
never  seen  the  operation  performed  under  these  circumstances  but 
once,  and  then  a  fatal  termination  soon  ensued.  But  I  have  re- 
cently met  with  two  cases  in  this  hospital, — the  New  York  Hos- 
pital— in  both  of  which  the  post-mortem  examination  made  me 
hesitate  as  to  the  propriety  of  the  course  pursued.  In  one  case, 
all  the  signs  of  hydro-pneumothorax  continued  until  death,  yet 
after  death  the  lungs  were  found  so  nearly  healthy,  the  tubercu- 
lous deposit  was  so  small,  that  I  could  not  help  thinking,  had  the 
operation  been  performed — this  was  decided  against  in  consulta- 
tion— the  life  of  the  patient  might  have  been  prolonged,  and  his 
condition  rendered  more  comfortable. 

"  Another  case  occurred,  in  which  the  signs  of  hydro-pneumo- 
thorax existed,  but  after  a  time  the  evidences  of  communication 
with  a  bronchus  ceased,  and  this  condition  continued  until  death. 
In  this  case,  also,  the  lungs  were  very  little  diseased,  and  the  open- 
ing into  the  bronchus  could  not  be  detected  by  inflating  the  lung. 
It  had  no  doubt  been  closed,  perhaps  by  being  covered  by  a  coat- 
ing of  lymph.  In  this  case,  and  for  a  still  stronger  reason,  the 
bronchial  communication  having  ceased,  the  operation  might  have 
aided  materially  in  prolonging  life. 

"  It  is  difficult  to  say  what  the  precise  condition  of  the  lung  is 
in  such  cases.  But  this  we  do  know,  that  hydro-pneumothorax 
occurs  most  frequently  when  there  are  but  few  tubercles  in  the 
lung.  A  copious  deposit  of  tubercles  leads  to  a  secondary  pleuri- 
sy with  effusion  of  lymph  only,  by  which  the  cavity  of  the  pleura 
tends  to  become  obliterated,  and  the  form  of  the  disease  I  am  now 
considering,  is  no  longer  likely  to  occur."  [Swell's  Lectures.] 

The  operation  for  empyema,  or  for  the  evacuation  of  other 
liquids  besides  pus,  from  the  cavity  of  the  chest,  is  very  ancient, 
being  referred  to  by  Hippocrates,  B.  C.  460,  as  well  as  by  many 
others  at  different  subsequent  periods  of  time.  Although  a  full 
description  of  this  operation  belongs  more  properly  to  works  on 
surgery,  yet  following  the  example  of  several  standard  authors, 
I  deem  it  best  to  insert  its  description,  as  given  in  Smith's  Opera- 
tive Surgery. 

The  diagnostic  physical  sigtis,  indicating  such  a  condition  as 
would  justify  the  operation,  are  enlargement  of  the  side,  dullness 


PLEURITIS.  253 

on  percussion,  absence   of  free  respiration,  vocal   resonance  and  a 
projection  or  fluctuation  in  the  intercostal  spaces. 

"  The  operation  of  paracentesis  thoracis  "  says  Dr.  Smith,  "  has 
been  variously  performed,  but  the  object  of  all  the  plans  is  to 
evacuate  the  liquid  contents  of  the  part,  without  admitting  air 
into  the  pulmonary  cavity.  To  accomplish  this,  it  has  been  sug- 
gested to  puncture  the  parietes  of  the  chest  with  a  trocar  and  can- 
ula,  or  with  a  trocar  and  syringe,  or  to  make  a  direct  dissection, 
layer  by  layer,  from  the  skin  to  the  pleura.  In  all  the  plans  that 
have  been  recommended  for  the  accomplishment  of  this  object, 
surgeons  have  differed  mainly  in  regard  to  the  best  point  for  the 
puncture ;  but,  as  the  patient  is  usually  compelled  to  su)  up.  and 
as  the  general  anatomical  relations  of  the  region  especially  favor 
a  certain  point,  it  is  sufficient  to  state  that,  when  circumstances 
admit  of  it,  the  space  between  the  fourth  and  fifth,  or  fifth  and 
sixth  ribs,  and  a  little  posterior  to  their  middle  should  be  selected. 

In  order  to  avoid  wounding  the  diaphragm,  which  is  presumed 
to  be  pushed  up  by  the  liver,  it  is  generally  advised  to  puncture 
the  right  pleura  one  rib  higher  than  that  advised  for  the  left. 
Such  a  position  is,  however,  far  from  being  established  as  correct, 
the  idea  being  based  rather  on  the  descriptions  of  the  normal  con- 
dition of  the  part  than  on  the  diseased  state,  and  it  is  most  prob- 
able that  the  weight  of  the  fluid  collected  within  the  right  pleura 
will  more  than  counteract  any  elevation  of  the  liver  when  the 
patient  is  in  the  erect  position.  In  counting  the  ribs  in  a  person 
of  moderate  flesh,  but  little  difficulty  will  be  found  in  tracing 
them  from  below,  upward  ;  but  in  those  who  are  fat,  or  in  those 
who  have  the  side  mdematous  and  swollen,  it  may  be  impossible 
to  distinguish  these  spaces,  and  under  such  circumstances  the  rule 
has  been  given  to  select  a  spot  which  is  about  six  finger-breadths 
below  the  inferior  angle  of  the  scapula.*" 

"  ORDINARY  OPERATIONS  OF  PAKACENTESIS  THORACIS. — The  pa- 
tient being  propped  up  in  bed,  and  a  little  inclined  to  the  sound 
side,  so  as  to  separate  the  ribs  as  much  as  possible  on  the  diseased 
side,  the  skin  is  to  be  divided  to  the  extent  of  one  and  a  half 

''•"  Malgaigne. 


THORACIC    DISEASES. 

inches  in  a  direction  parallel  with  the  superior  edge  of  the  low- 
est rib  on  the  intercostal  space,  that  is  selected  for  the  puncture. 
After  dividing  the  superficial  fascia,  and  any  portion  of  a  muscle 
of  the  chest  that  may  intervene,  as  well  as  the  external  and  in- 
ternal intercostal  muscles,  the  pleura  will  be  found  generally  to 
bulge  into  the  wound.  After  being  distinctly  felt  by  the  fore- 
finger, so  as  to  establish  the  fact  that  only  fluid  is  behind  it,  the 
puncture  should  be  made  with  the  point  of  a  bistoury,  and  the 
opening  gradually  enlarged  as  the  liquid  escapes.* 

"  If  the  pleura  is  very  much  thickened,  care  will  be  requisite  to 
avoid  the  error  of  pushing  it  before  the  instrument.  Velpeau  en- 
tertains the  opinion  that  in  cases  which  require  the  operation,  the 
effused  liquid,  or  even  an  abscess,  will  remove  the  lung  from  the 
point  of  puncture.  He,  therefore,  objects  to  the  details  just  given, 
and  advises  that  the  side  of  the  chest  be  at  once  opened  by  a  deep 
puncture  with  the  bistoury  in  the  same  manner  as  an  ordinary 
abscess. 

"  AFTER  TREATMENT. — If  circumstances  render  it  desirable  to 
keep  the  wound  open,  a  tent  may  be  introduced,  and  removed 
from  day  to  day  ;  but  if  the  whole  of  the  liquid  be  evacuated, 
the  opening  may  be  at  once  closed  with  adhesive  strips,  a  com- 
press, and  bandage. 

"  If  the  subsequent  discharge  continues  copious,  or  becomes 
very  fetid,  advantage  may  be  derived  from  washing  out  the  cavi- 
ty with  warm  water,  or  warm  barley  water ;  weak  astringent 
washes,  or  those  of  an  anti-septic  character,  being  subsequently 
employed.  In  order  to  evacuate  the  liquid,  and  yet  prevent  the 
entrance  of  air,  various  contrivances  have  been  employed.  Pelle- 
tan  employed  a  syringe  for  this  purpose,  and  Reybard  placed  a 
piece  of  gold-beater's  skin,  or  the  intestine  of  the  cat.  over  a 
canula  introduced  into  the  pulmonary  cavity,  by  means  of  a  per- 
foration in  the  rib,  so  that  the  matter  might  flow  out  and  yet  the 
air  not  enter. 

"  Dr.  Wyman,  of  Cambridge,  Mass.,  has  invented  a  brass  suc- 
tion-pump with  an  exploring  canula,  in  order  to  permit  the  evac- 

"  Yelpeau's  Op.  Surg.,  by  Mott,  p.  olo,  v.  iii. 


PLEURITIS.  255 

nation  of  the  fluid  without  allowing  the  air  to  enter  the  pleura, 
and  has  reported  numerous  instances  of  the  success  of  this  mode 
of  operating,  which  he  thinks  is  preferable  to  the  ordinary  mode 
of  incising  the  soft  parts. 

"  REMARKS. — The  value  of  the  operation  of  paracentesis  tho- 
racis  has  been  differently  estimated  at  various  periods ;  most  of  the 
surgeons,  up  to  the  time  of  Laennec,  having  regarded  it'  as  a 
doubtful  or  dangerous  operation,  especially  from  the  difficulties 
attendant  on  the  diagnosis.  Since  the  more  general  resort  to  aus- 
cultation, many  of  these  difficulties  have  been  removed. 

"  But,  though  the  cases  can  now  be  better  selected  than  they 
were  formerly,  a  successful  result  is  not  always  obtained.  The 
true  results  of  the  operation  may,  it  is  thought,  be  correctly  stated 
thus  : — Paracentesis  always  affords  temporary  relief,  and  almost  one- 
half  of  the  cases  recover  ;  but  whether  these  patients  would  have 
died  without  it,  it  is  diflicult  to  tell. 

"  The  idea  is  certainly  erroneous  that  paracentesis  thoracis  is 
an  eminently  successful  operation,  and  though  its  results  have 
been  such  as  to  justify  its  performance,  the  prognosis  should  be 
guarded.  From  statistics  collected  from  various  sources,  it  appears 
that  the  mortality  is  considerable,  and  the  objections  that  have 
been  raised  against  the  operation  in  former  days  should  be  regard- 
ed. They  are  thus  stated  by  Velpeau  : — 

"If  the  lung  has  been  forcibly  compressed  by  the  liquid,  and 
yet  is  permeable,  the  evacuation  of  the  liquid  without  the  en- 
trance of  air  into  the  pulmonary  cavity  may  distend  it  so  rapidly 
as  to  excite  violent  inflammation.  If,  on  the  contrary,  the  lung 
has  shrunk  so  much  as  to  yield  but  slowly  to  the  entrance  of  air, 
the  void  which  is  immediately  left  about  the  parts,  is  very  liable 
to  derange  the  respiration  and  pectoral  circulation.  The  intro- 
duction of  air  into  the  cavity  of  the  pleura,  though  obviating  this, 
yet  exposes  the  patient  to  danger  by  exciting  the  inflammation, 
and  creating  unhealthy  pus,  thus  giving  rise  to  adynamic  symp- 
toms, under  which  many  have  died. 

"  KSTIMATE  OF    THE  OPERATION. — In   estimating  the    value   of 

O  ^ 

any  of  these   modes  of  operating,   the   difficulties    or  objections 


2  50  THORACIC    DISEASES. 

applicable  to  each  should  not  be  overlooked.  When  the  intei> 
costal  spaces  are  prominent,  and  the  presence  of  liquid  certain, 
the  direct  puncture  of  Yelpeau  is  best. 

"  When  there  is  any  doubt  of  the  position  of  the  liquid,  then 
the  ordinary  operation  by  dissection  of  layers  would  be  prefera- 
ble. Where,  however,  the  diagnosis  is  positive,  and  the  chances 
of  failure  from  the  accident  of  pushing  forward  the  thickened 
membrane,  instead  of  perforating  it,  is  guarded  against,  the  in- 
strument of  Dr.  Wyman  of  Massachusetts  may  prove  advan- 
tageous. In  Boston,  the  experience  of  the  profession  is  said  to 
be  favorable  to  it. 

"  Under  all  circumstances,  the  surgeon  may  anticipate  an  anx- 
ious and  long-continued  convalescence  of  the  patient,  and  one 
which  will  exact  all  his  skill  as  a  practitioner,  to  conduct  the 
case  to  a  favorable  result. 

"  The  employment  of  a  trocar  is  the  most  objectionable  of  the 
various  instruments  employed,  as  it  is  not  so  shaped  as  to  obtain 
a  keen  edge,  whilst  the  point  of  the  cannula,  even  when  closely 
fitted  to  the  shoulder  of  the  instrument,  is  very  liable  to  tear  or 
push  the  pleura  before  it,  as  is  occasionally  seen  in  cases  of  hydro- 
cele,  accompanied  with  thickening  of  the  tunica  vaginalis. 

"  When  the  surgeon  recalls  the  constitutional  effects  liable  to 
result  from  opening  closed  cavities,  and  especially  those  contain- 
ing pus,  and  covered  by  a  pyogenic  membrane,  he  can  readily 
foresee  the  consequences  of  opening  the  pleura  in  cases  of  em- 
pyema.  The  natural  tendency  of  such  collections  is  either  to  be 
absorbed  or  discharged  by  the  efforts  of  nature.  If  discharged 
by  nature  the  inflammation  of  the  surrounding  parts,  and  the 
character  of  the  opening  made  by  ulceration,  are  well  known  to 
be  more  favorable  to  a  cure  than  is-  the  case  when  the  surgeon 
punctures  it.  I  would,  therefore,  express  the  opinion  that  this 
operation  should  not  be  resorted  to  until  the  latest  possible  mo- 
ment ;  that,  when  done,  air  should  be  prevented  from  entering 
the  cavity  of  the  chest ;  that  the  pus  should  be  slowly  and  only 
partially  discharged,  the  wound  closed,  and  the  operation  repeated, 
if  necessary.  If,  however,  the  entrance  of  air  cannot  be  pre- 
vented, it  will  be  better  to  evacuate  the  whole  of  the  liquid,  and 
treat  the  case  subsequently  like  one  of  abscess." 


PLEURIT1S.  257 

Prom  statistics,  it  appears  that  nearly  two-thirds  of  the  cases 
operated  on  have  been  cured.  [Smith's  Operative  Surgery.] 

The  result  of  the  operation,  though  more  favorable  than  some 
authors  represent,  should  teach  the  importance  of  using  all  possi- 
ble preventive  means,  in  order  to  avoid  the  necessity  of  its  per- 
formance. The  question,  then,  very  naturally  arises,  can  any 
means  more  efficient  than  those  in  common  use  among  allopathic 
physicians,  be  used  to  prevent  the  recurrence  of  its  necessity  ?  I 
think  so.  The  object,  as  has  been  before  stated,  is  to  promote  ab- 
sorption, and  to  sustain  the  strength  of  the  system  while  the  cur- 
ative process  is  going  on.  Ordinarily  physicians  depend,  for  the 
most  part,  upon  diuretics  and  tonics;  seldom  using  as  curative 
agents  emetics.  But  notwithstanding  this,  these  when  properly 
used,  and  composed  of  such  articles  as  produce  temporary  debil- 
ity only,  are  in  rny  opinion  of  great  service.  In  acute  pleurisy 
they  have  had  the  sanction  of  Riverius,  Ruland,  Blegny,  Mur- 
sinna,  Morgagni,  Wright,  Stoll,  Tissot,  Ackermann,  and  Schel- 
hammer.  And  Dr.  Copeland  adds  that,  when  discreetly  pre- 
scribed, they  are  important  aids  in  the  treatment  of  most  of  the 
forms  of  the  disease. 

Dr.  Gallup  observes  "  that  the  character  of  the  chronic  morbid 
habit  leads  us  to  infer,  that  certain  operations  which  may  bring 
into  exercise  the  minute  circulations,  may  be  useful  to  restore 
their  integrity  of  function.  One  adjuvant  has  been  found  in  the 
exercise  of  vomiting ;  and  we  make  it  a  substitute  for  corporeal 
exercise  for  those  not  in  a  condition  for  this.  Not  only  so,  but  it 
exercises  every  minute  tissue  more  effectually  than  any  mere  mus- 
cular exercise.  It  is  necessary  that  this,  with  other  processes, 
should  precede,  and  prepare  the  system  to  endure  muscular  mo- 
tion with  benefit  by  removing  the  morbid  derangements. 

"  The  lungs  as  well  as  all  the  internal  organs,  are  exercised  by 
emesis,  and  their  functions  promoted  by  it.  The  exhalents  and 
mucous  follicles  discharge  more  freely,  and  the  internal  infarc- 
tions of  the  blood  vessels  are  agitated,  and  absorptions  promoted. 
The  centrifugal  and  exhaling  surfaces  are  excited,  not  by  direct 
stimulants,  which  would  add  to  the  diseased  state,  but  by  a  train 
of  associate  motions  restoring  or  exciting  their  lost  functions. 
Even  the  exercise  of  nausea  is  extended  very  considerably  to  all 


258  THOllACIC    DISEASES. 

the  tissues,  and  in  many  conditions  may,  where  there  is  much 
lowness,  be  used  as  an  occasional  substitute  for  emesis.  These 
processes  may  be  so  conducted  as  not  to  exhaust  overmuch. 
Like  corporeal  exercise,  they  may  be  extended  to  the  point  of  fa- 
tigue but  not  of  exhaustion. 

"  It  is  not  a  single  emesis  that  will  be  of  much  use,  to  remove 
a  fixed  state  of  disease  of  slow  access ;  but  it  must  be  reiterated, 
and  in  connection  with  other  auxiliaries.  The  patient  should 
always  be  in  a  warm  condition  during  the  process,  so  as  to  pro- 
mote dermoid  action,  and  sometimes  moderate  sweats." 

Emetics,  it  seems  to  me,  are  for  another  reason,  useful  in  chron- 
ic pleuritis.  One  object  is  to  produce  expansion  of  the  com- 
pressed lung.  While  the  emesis  promotes  absorption  of  the  ef- 
fused fluids,  it  also,  by  producing  deep  inspirations,  expands  the 
lung,  which,  in  consequence  of  its  sudden  increase  in  size,  excites 
still  more  the  function  of  absorption.  They,  also,  when  com- 
posed of  proper  articles,  and  properly  administered,  prepare  the 
system  for  the  effectual  application  of  tonic  remedies.  To  pre- 
scribe this  latter  class  of  curative  agents,  when  the  mucous  mem- 
branes are  coated  with  morbid  secretions,  is  worse  than  useless. 
I  have 'seen  patients  laboring  under  some  chronic  disease  of  the 
pleura,  who  had  been  treated  with  tonics  with.no  benefit,  rapidly 
recover  after  the  administration  of  an  emetic,  followed  by  the 
use  of  those  very  remedies,  which  they  had  before  been  using 
with  no  salutary  effect. 

They  should  be  repeated  once  a  day,  or  once  in  two  or  three 
days,  according  to  the  degree  of  benefit  received  from  them.  A 
very  good  lime  is  in  the  evening  about  an  hour  after  coming  from 
a  warm  bath.  Some  who  suffer  much  in  the  morning  from  col- 
lections of  muco-purulent  matter,  receive  the  most  benefit  by 
using  the  emetic  at  this  time. 

The  intervals  between  their  administration  should  be  sufficient- 
ly long  to  afford  rest  and  refreshment  to  the  patient.  Nor  should 
he,  in  the  interval  be  continually  harrassed  by  other  medicines  of 
doubtful  utility.  A  nutritious  diet  should  be  used,  and  all  food 
containing  but  little  nutriment  in  a  large  bulk  should  be  avoided. 

My  manner  of  administering  the  emetic  in  very  feeble  patients 
is  this: — I  give,  after  the  patient  is  warm  in  bed,  and  his  stom- 


PLEURITIS.  259 

ach  is  somewhat  distended  with  warm  water,  at  suitable  inter- 
vals, a  pill  containing  from  gr.  ii  to  gr.  iv.  of  extract  of  lobelia, 
until  considerable  nausea  is  produced.  Then  I  direct  the  copious 
drinking  of  warm  water  which  in  a  few  moments  is  usually  fol- 
lowed by  an  easy  and  free  evacuation  of  the  contents  of  the 
stomach.  In  other  cases,  when  the  patient  can  bear  more  heroic 
treatment,  the  pursuit  of  the  above  course  is  not  necessary,  but 
the  emetic  may  be  given  in  the  ordinary  way.  In  case  much 
distress  results  from  the  effects  of  the  emetic,  administer,  in  cold 
water,  and  repeat  the  same,  acetic,  or  citric  acid. 

The  means  chiefly  to  be  relied  upon,  in  warding  off  the  neces- 
sity for  an  operation,  are  the  vapor  bath  followed  by  brisk  fric- 
tion, gentle' and  repeated  emetics,  followed  by  the  strongest  ton- 
ics, and  nourishing  food,  and  vegetable  diuretics.  Inhaling  tubes 
for  the  purpose  of  expanding  the  compressed  lung,  are  by  some 
highly  recommended.  When  the  effusion  has  a  purulent  charac- 
ter, the  hydriodate  of  potassa  in  the  dose  of  two  or  three  grains, 
three  times  a  day  is  often  useful ;  in  more  asthenic  cases,  the 
iodide  of  iron,  in  rather  small  doses  may  bo  given.  For  a  diu- 
retic, when  the  vegetable  diuretics  before  mentioned,  fail  to  give 
relief,  the  tartrate  of  iron  is  serviceable,  especially  where  a  dropsi- 
cal diathesis  prevails. 

SECTION  IV. 
LATENT    P  L  E  U  R I T  I  S . 

This  variety  differs  from  others  mainly  in  the  absence  of  the 
more  common  rational  symptoms,  such  as  Tlyspnoea,  congh  and 
pain.  These  are  cither  entirely  wanting  or  are  so  imperfectly  de- 
veloped as  to  make  it  impossible  to  found  upon  them  an  accurate 
diagnosis.  The  disease  passes  so  insidiously  through  its  different 
stages,  that  the  patient  is  seldom  aware  of  the  nature  of  the  mal- 
ady with  which  he  is  atiectcd.  After  recovery  he  often  forgets 
the  trifling  indisposition  which  he  felt  during  its  progress.  In  this 
form  of  pleuritis  adhesions  of  the  lungs  to  the  costal  pleura  often 
become  extensive.  In  rare  cases  the  general  symptoms  are  more 
marked,  attended  with  a  gradual  wasting  of  the  vital  forces.  In 
general  such  cases  are  complicated  with  phthisis. 


260  THORACIC    DISEASE?. 

PATHOLOGY. — The  anatomical  lesions  in  latent  pleuritis  differ 
so  little  from,  those  already  described,  that  their  consideration  in 
this  place  would  be  but  a  useless  repetition. 

DIAGNOSIS. — The  absence  of  the  rational  symptoms,  makes  the 
diagnosis  dependent  almost  wholly  upon  the  physical  signs.  In 
case  there  is  considerable  effusion,  we  have  dullness  on  percussion, 
feeble  respiration  and  egophony. 

Additional  evidence  of  the  pleuritic  character  of  the  disease  is 
afforded  by  the  existence  of  the  friction  sound.  In  case  this  is 
absent  and  the  other  signs  above  referred  to  are  but  imperfectly 
developed,  there  is  danger  of  confounding  the  disease  with  enlarge- 
ment of  the  liver,  or  with  consolidation  of  the  lung.  In  the  ma- 
jority of  cases,  however,  the  physical  signs  are  so  well  marked 
that  a  correct  diagnosis  may  be  made.  With  tuberculous  disease 
it  is  often  so  intimately  connected  that  it  is  difficult  to  determine 
how  many  of  the  morbid  phenomena  proceed  from  the  tubercular 
deposits,  and  how  many  from  the  pleuritic  inflammation.  Almost 
always  in  those  of  a  scrofulous  diathesis,  these  two  diseases  are 
more  or  less  mingled  together ;  and  hence,  in  such  persons,  the 
slightest  symptoms  of  phthisis  occurring  in  pleuritis  should  be 
closely  observed. 

PROGNOSIS. — The  prognosis  is  favorable  or  unfavorable  accord- 
ing to  the  nature  of  its  complicating  diseases,  and  the  condition 
of  the  constitution.  When  associated  with  phthisis  there  is  but 
little  reason  to  hope  for  recovery ;  when  isolated  and  occurring  in 
a  healthy  constitution,  it  generally,  under  proper  treatment,  ter- 
minates favorably. 

i 
TREATMENT. — The  treatment  does  not   materially  differ  from 

that  of  other  chronic  forms  of  the  disease.  There  is,  therefore, 
no  need  of  any  repetition  in  this  place,  of  that  which,  under  the 
head  of  Chronic  Pleurisy,  is  fully  described.  The  remedies  should, 
of  course,  be  continued  until  all  physical  signs  of  the  disease  dis- 
appear, and  the  general  healthy  appearance  of  the  patient  is  indi- 
cative of  complete  recovery. 


PLEUR1TIS.  261 

SECTION  V. 
SECONDARY  AND   COMPLICATED  PLEURITIS. 

PATHOLOGY. — Pleuritis  is  often  associated  with  inflammation  of 
an  adjoining  tissue  or  organ,  or  with  some  other  lesion  or  malady. 
It  may  be  either  primary  or  secondary.  With  inflammation  of 
the  parenchyma  of  the  lung  it  is  frequently  complicated ;  the  dis- 
ease sometimes  beginning  in  the  pleura  and  extending  to  the  sub- 
stance of  the  lung ;  at  other  times,  on  the  contrary,  beginning  in 
the  lung  and  extending  to  the  pleura.  This  complication  is  usu- 
ally termed  pleuro-pneumonia,  and  by  older  writers  was  known 
by  the  name  peripneumonia.  In  such  cases  the  inflammation  usu- 
ally assumes  a  sthenic  character.  The  pleuritic  and  the  pulmonic 
inflammation  may  be  coetaneous.  More  often,  however,  the  pul- 
monic, is  antecedent  to  the  pleuritic  than  the  reverse. 

Some  writers  assert  that  the  complication  of  pneumonitis  with 
pleuritis  lessens  instead  of  increasing  the  danger.  The  reason 
given  is  derived  from  the  idea  that  the  pneumonia  is  lessened  by 
the  pressure  of  the  effused  fluids  of  pleuritis.  The  lung  also  by 
its  increased  size,  in  consequence  of  the  engorgement  of  its  ves- 
sels, presses  upon  the  fluids,  and  this  excites  a  degree  of  activity 
in  the  absorbents,  which  under  other  circumstances  would  not 
exist.  There  is,  then,  according  to  this  theory,  a  reciprocity  of 
action,  whose  tendency  is  to  the  cure  of  the  disease. 

Pleurisy  is  sometimes  complicated  with  exanthematous  and  con- 
tinued fevers.  Unless  it  occurs  in  the  period  of  convalescence 
from  these  maladies,  it  is  prone  to  assume  the  sthenic  form,  but 
when  during  recovery  the  fluids  of  the  body  are  contaminated, 
and  the  vitality  of  the  system  depressed,  the  asthenic  form  is 
most  common.  Whenever,  in  fevers,  the  breathing  becomes  very 
short  and  frequent,  whether  or  not  accompanied  with  pain  in  the 
side  and  cough,  then  pleuritic  inflammation  may  be  suspected,  and 
an  examination  should  be  immediately  made  in  order  to  arrive  at 
a  correct  diagnosis,  and  predict  with  certainty  the  nature  of  the 
termination. 


262 


THORACIC    DISEASES. 


Another  very  frequent  complication  of  pleurisy  is  with  phthisis 
and  chronic  tubercular  pneumonitis.  Tubercles  existing  near  the 
surface  of  the  lung,  often  excite  inflammation  in  the  circumjacent 
tissues,  which  is  readily  extended  to  the  pleura  pulmonalis.  On 
its  free  surface  lymph  is  effused,  which,  coming  in  contact  with 
the  pleura  costal  is,  excites  on  it  inflammation.  Adhesion  usually 
is  the  result.  Sometimes,  however,  a  different  state  of  things 
takes  place.  A  cavity,  by  the  .softening  of  tubercular  deposits,  is 
formed  near  the  surface  of  the  lung  before  adhesion  is  effected. 
This,  in  some  cases,  producing  a  perforation  of  the  pleura  pul- 
monalis, and  at  the  same  time  communicating  with  the  bronchial 
tubes,  admits  into  the  cavity  of  the  pleural  sac,  the  atmosphere. 
This  kind  of  lesion  is  called  pneumothorax,  which,  in  another 
place,  will  be  more  fully  considered. 

Tuberculous  pleurisy  may  be  consecutive  to  tubercular  depos- 
its in  the  parenchyma  of  the  lungs,  and  then  it  is  strictly  secon- 
dary. Again,  in  the  second  place,  it  may  arise  from  the  deposit 
of  tubercles  in  the  pleura  itself;  and,  lastly,  the  inflammation  of 
the  pleura  is  antecedent  to  the  tubercular  deposit,  the  pleuritis 
thus  becoming  an  exciting  cause  of  phthisis.  The  latter  effect 
of  pleuritic  inflammation  should  then  be  considered  in  this  con- 
nection. Why  is  pleuritis  more  prone  to  produce  tubercular  dis- 
ease, than  pneumonitis  ?  To  answer  this  may  be  difficult ;  and 
yet  such  is  the  fact.  May  not  the  absorption  of  pus  into  the 
blood  be  one  prominent  cause  ?  This,  like  all  other  impure  mat- 
ter in  the  blood,  must  tend  to  produce  more  or  less  debility,  must 
excite  an  irritative  fever  simulating  the  hectic  of  phthisis. 

That  febrile  action  which  most  nearly  resembles  the  hectic  of 
phthisis,  should  cseteris  paribus  be  most  likely  to  afford  conditions 
most  favorable  to  the  development  of  tubercles.  This  may  be 
one  cause  of  the  tendency  of  pleuritis  to  generate  phthisis. 

Pleuritis  is  also  complicated  with  many  other  diseases,  with 
pericarditis,  hepatitis,  peritonitis,  and  rheumatism.  These  com- 
plications, however,  are  not  sufficiently  common  to  be  made  sub- 
jects of  separate  consideration. 

DIAGNOSIS. — The  diagnosis  in  complicated  pleuritis,  must  de- 
pend upon  that  accurate  discrimination  in  the  balance  of  symp- 


PLEURITIS.  263 

toms,  which  is  the  possession  of  every  close  observer  of  disease. 
Each  symptom  is  often  a  complex  phenomenon,  divisible  into  a 
number  of  separate  signs.  If  in  the  course  of  pneumonitis,  the 
friction  sound  occurs,  if  there  is  great  dullness  on  percussion,  the 
limits  of  which  change  on  every  change  of  posture,  if  there  is 
egophony,  if  either  one  or  all  of  these  physical  signs,  are  com- 
bined with  those  of  pneumonitis,  the  diagnosis  will  be  evident. 
Complications  with  phthisis  will  of  course,  give  the  signs  of  both 
diseases ;  with  pericarditis,  will  give  the  friction  sound  of  pleu- 
ritis  heard  only  during  respiration  ;  while  the  friction  sound  of 
pericarditis  is  heard  during  the  suspension  of  respiration.  The 
effusion,  and  consequent  dullness  of  pericarditis  is  confined  to  a 
small  space — the  preecordia  ;  that  of  pleuritis  extends  over  the  base 
and  sides  of  the  lung  and  is  in  general  changed  by  any  change 
of  posture.  When  both  these  trains  of  symptoms  are  coetaneous, 
the  nature  of  the  complication  will  be  evident.  The  diagnosis  of 
other  complications  must  depend  upon  principles  similar  to  those 
already  suggested. 

The  PROGNOSIS  will  depend  upon  three  conditions,  the  nature 
of  the  complicating  disease,  the  extent  of  the  pleuritis  and  the 
constitutional  state  of  the  patient.  Pleuro- pneumonitis,  has  al- 
ready been  referred  to.  Pleuritis  complicated  with  phthisis  is 
always  very  dangerous  ;  with  pericarditis  it  is  unfavorable. 

TREATMENT. — The  complications  of  pleuritis  necessarily  involve 
the  same  principles  of  treatment  as  the  more  distinct  forms  of  the 
disease.  Regard  must  be  had  to  the  nature  of  the  malady  with 
which  the  pleuritis  is  associated.  If  its  complication  be  with 
some  other  sthenic  inflammatory  disease,  the  anti-inflammatory 
means  must  be  used  in  the  process  of  cure.  If  associated  with 
pneumonitis,  all  narcotics  should  be  used  with  more  caution 
than  in  its  simple  form.  When  arising  from  the  retrocession 
of  eruptions  from  the  surface,  warm  bathing  with  stimulants  and 
diaphoretics  should  be  used.  When  complicated  with  phthisis, 
the  treatment  for  the  latter  disease  is  most  appropriate. 


264  THORACIC  DISEASES. 

SECTION    VI. 
PLEURITIS     OF    CHILDREN. 

Pleurisy  is  common  in  children  of  all  ages  ;  but  is  most  fre- 
quent in  its  uncomplicated  forms  after  the  age  of  five  years. 
Anterior  to  that  period  it  is,  in  general,  associated  with  pneumon- 
itis  and  bronchitis.  Sometimes  it  is  a  sequela  of  eruptive  fevers. 
During  the  whole  period  of  convalescence  from  them,  while  the 
functions  of  the  skin  are  but  partially  restored,  this  disease  in 
children  is  prone  to  occur. 

PATHOLOGY. — Primitive  pleurisy  in  young  children  does  not 
present  any  striking  anatomical  characteristics  which  distinguish 
it  from  the  disease  in  adults,  as  in  the  case  of  pneumomtis. 
There  is,  however,  one  fact  in  those  cases,  which  points  out  the 
affection.  It  is  a  want  of  compressibility  in  the  lung  from  the 
liquid  effusion.  The  effect  of  this  is  seen  in  the  modification 
of  the  physical  signs  which  it  produces. 

DIAGNOSIS. — Dullness  on  percussion  presents  its  usual  charac- 
teristics. But  the  respiratory  murmur,  on  the  contrary,  instead  of 
being  feeble  or  absent,  assumes  a  bronchial  character,  equally  as 
distinct  as  that  of  pneumonitis,  but  far  more  extensive,  accom- 
panying the  dullness  on  percussion,  and  being  often  heard  all 
over  the  affected  side,  and  without  crepitation  or  rhonchus. 
"This  bronchial  respiration"  says  Dr.  Swett,  "as  connected 
with  pleuritis,  is  the  rule,  in  the  pleurisy  of  young  children,  not 
the  exception,  as  in  that  of  adults." 

PROGNOSIS. — Pleuritis  in  children  is  far  more  dangerous  than  in 
adults ;  more  especially  when  it  occurs  as  the  sequela  of  eruptive 
fevers,  of  pneumonitis,  or  pertussis.  In  infants  this  disease, 
whether  simple  or  complicated  with  pneumonitis,  bronchitis  or 
whooping-cough,  is  often  fatal.  In  twenty-four  hours,  by  caus- 
ing suffocation,  it  may  end  in  death.  In  very  young  children 
it  seldom  assumes  a  chronic  form  ;  for  in  them  the  later  stages  of 
the  disease  are  less  liable  to  occur. 


PNEUMOTHOKAX.  265 

TREATMENT. — Pleurisy  in  children  requires  the  same  measures 
which  are  recommended  for  adults,  modified  according  to  age 
and  to  the  susceptibility  of  infancy  to  the  influence  of  reme- 
dies. Relaxing  enema  should  be  more  frequently  directed,  and 
the  use  of  the  more  harsh  and  debilitating  means,  more  cautiously 
prescribed.  Warm  demulcent  poultices,  instead  of  irritants  or  ves- 
icants, should  be  employed.  In  the  chronic  form,  the  frequent 
sponging  of  the  surface  with  warm  salt  water,  as  an  external  ap- 
plication, is  excellent.  For  an  internal  remedy,  the  sirup  of  the 
iodide  of  iron,  administered  in  simple  sirup  of  sugar,  is  sometimes 
serviceable  as  a  tonic. 

Other  varieties  and  modifications  of  pleurisy  are  described 
by  some  authors.  But  they  are  for  the  most  part,  unimportant, 
and  their  consideration  is  of  no  practical  utility. 


CHAPTER  XII. 

P  N  E  U  M  0  T II 0  11 A  X  . 

The_  term  pneumothorax  from  the  Greek  TTVSU^OC  air  and 
chest,  which  would,  according  to  its  etymology,  mean  any  collec- 
tion of  air  in  the  chest,  is  at  present,  used  to  designate  more  es- 
pecially the  effusion  of  aeriform  fluids  in  the  cavity  of  the  pleura, 
whether  the  air  exists  alone,  or  whether/there  is  sometimes  a  cer- 
tain quantity  of  liquid  mingled  with  it.  In  the  first  instance  the 
collection  receives  the  name  of  pneumothorax,  in  the  latter  that 
of  hydro-pncumothorax.  Notwithstanding  the  distinctive  use  of 
these  terms,  the  name  pneumothorax  is  in  general  applied  to  both 
of  these  phenomena. 

Before  the  commencement  of  the  present  century,  it  had  not 
been  made  a  subject  of  thorough  investigation.  To  Laennec  be- 
longs the  honor  of  first  making  it  an  object  of  scientific  study. 

PATHOLOGY. — Pneumothorax  is  a  consequence  of  lesions  of  both 

the  lungs  and  pleura.      In  most  cases  it  is  the  result  of  tubercular 

disease  perforating  the  pleura  pulmonalis,  before  it  adheres  to  the 

.pleura  costalis.     The  cavity  formed  by  tubercles  communicating 

34 


266  THORACIC    DISEASES. 

with  the  pleural  sac,  and  at  the  same  time  with  the  bronchial 
tubes,  gives  rise  to  this  affection.  Sometimes  pneumothorax  oc- 
curs in  gangrene  of  the  lungs.  A  gangrenous  eschar  may  break 
into  the  pleural  sac,  and  a  communication  be  formed  with  the 
bronchi.  It  is  possible  for  an  emphysematous  vesicle  in  the 
lung  to  rupture  the  pleura  covering  it,  and  thus  produce  a  pneu- 
mothorax. 

Another  way  by  which  this  has  been  supposed  to  be  produced, 
is  the  secretion  of  air  by  the  absorbing  surfaces  of  the  pleura,  or 
by  the  decomposition  of  inflammatory  products.  A  fistulous 
opening  or  wounds  produced  by  accident  or  by  the  hand  of  the 
surgeon  sometimes  are  its  immediate  cause. 

When  the  air  enters  the  cavity,  it  compresses  the  lung  and  gives- 
rise  to  the  physical  signs  of  this  organic  lesion.  Perforations  of 
the  pleura,  as  we  should  expect  from  the  more  frequent  location 
of  tubercles  in  the  left  lung,  oftener  are  found  on  the  left  than  on 
the  right  side.  Reynaud  found  in  forty  cases  of  perforation,  twenty- 
seven  on  the  left  lung,  and  thirteen  on  the  right. 

DIAGNOSIS. —  General  symptoms.  These  are  very  equivocal, 
and  altogether  insufficient  to  serve  as  the  basis  of  a  confident  di- 
agnosis. Dyspnoea  caused  by  the  compression  of  the  lung  is  a 
very  constant  symptom.  Its  degree  depends  upon  the  amount  of 
air  and  liquid  in  the  cavity  of  the  pleura,  upon  the  rapidity  and 
permanence  of  the  accumulation,  and  upon  the  condition  of  the 
opposite  lung.  Casteris  paribus  the  dyspnoea  will  be  less,  when 
the  admission  of  air  or  the  collection  of  other  fluids,  is  gradual ; 
because  the  organs  of  respiration  and  circulation,  to  a  certain  ex-1 
tent,  accommodate  themselves  to  the  new  condition. 

Most  frequently  it  happens  that  the  entrance  of  the  air  is  sud- 
den, and  as  a  consequence,  dyspnoea  quickly  becomes  severe  at- 
tended with  acute  pain,  and  sometimes  with  a  sensation  as  if 
something  had  given  way  in  the  chest.  In  case  the  pleural  sac  is 
distended  with  pus,  a  copious  expectoration  of  a  puriform  charac- 
ter suddenly  supervenes  as  a  result  of  the  opening  into  the  pleura. 
Sometimes  it  so  happens  that  the  pleural  opening  is  so  large  as> 
to  permit  a  ready  egress  of  the  air  admitted  into  the  pleura,  in 
which  case  the  dyspnoea  will  be  less  violent.  On  the  contrary,  if 


PNEUMOTHORAX.  267 

the  opening  be  such  as  to  permit  the  passage  of  air  only  one  way, 
like  the  valve  of  a  pump,  then  at  every  inspiration  more  air  is  ad- 
mitted than  is  expired,  until  the  accumulation  is  so  great  as  to 
cause  suffocation.'  Very  soon,  under  such  circumstances,  death 
may  occur,  preceded  by  the  most  painful  and  laborious  breathing, 
intense  anxiety  and  general  prostration.  When  one  lung  from  the 
effects  of  the  disease  is  unfitted  alone  to  arterialize  sufficient  blood 
to  sustain  life,  and  the  pneumothorax  occurs  on  the  other  side, 
sudden  death  is  almost  inevitable. 

When  communication  first  takes  place  between  the  lung  and 
pleural  cavity,  there  is  not  only  dyspnoea,  but  also  sharp  pain  and 
cough,  in  consequence  of  the  irritation  of  the  pleura.  This  is 
sometimes  very  severe ;  so  much  so  as  to  cause  a  great  depres- 
sion of  the  vital  powers.  This,  however,  is  usually  followed  by 
reaction,  giving  rise  to  the  ordinary  symptoms  of  fever.  The 
cause  of  this  irritation,  by  many,  has  been  supposed  to  arise  di- 
rectly from  the  contact  of  air  with  the  serous  membrane,  the 
pleura.  Concerning  this,  there  is,  however,  some  doubt.  A  prob- 
ability exists,  that  the  acid  matter  from  vomicse,  drawn  into  the 
pleural  sac  with  the  air,  produces  much  of  the  effect  usually  as- 
cribed to  another  cause,  [ti  case  liquid  exists  in  the  pleura,  ante- 
rior to  the  ingress  of  air,  its  admission  would  be  very  apt  to  pro- 
duce chemical  changes  in  the  effused  substances,  and  thus  secon- 
darily cause  irritation.  In  general,  the  sitting  posture  is  most 
agreeable  to  the  patient,  or  if  he  lies  down,  the  decubitus,  after 
the  pleuritic  pain  has  subsided,  is  on  the  affected  side. 

Special  symptoms.  Without  some  more  sure  means  of  detect- 
ing the  existence  of  pneumothorax  than  the  general  symptoms,  a 
correct  diagnosis  could  not  without  great  difficulty,  if  at  all,  be 
determined.  Of  all  the  diseases  affecting  the  chest,  this,  though 
once  so  obscure,  has  now  become  by  the  aid  of  the  physical  signs, 
the  most  easily  detected.  As  soon  as  the  air  enters  the  pleural 
sac,  the  lung  collapses,  and  consequently  less  air  is  inspired.  The 
effect  of  this,  is  to  lessen  the  respiratory  murmur  on  the  affected 
side. 

Under  such  circumstances,  what  does  percussion  reveal  ?  The 
pleura  distended  with  gas,  and  the  lung  collapsed,  afford  condi. 
tions  which,  from  reason  we  should  expect  to  favor  the  production 


268  THORACIC    DISEASES. 

of  great  resonance.  And  thus  we  find  it  to  be.  On  the  diseased 
side,  we  get  the  drum-like  sound  on  striking  the  chest,  while  on 
the  opposite  side  we  have  more  flatness  on  percussion,  but  a 
louder  respiratory  murmur.  So  that  the  physical  signs  on  the 
two  lungs,  are  opposite.  On  the  diseased  side  there  is  great  res- 
onance, but  very  feeble  if  any  respiratory  murmur.  On  the 
healthy  lung,  the  resonance  is  less  than  on  the  other,  but  the  res- 
piratory murmur  is  more  distinct  than  natural.  As  the  disease  ad- 
vances, and  pus  collects,  or  if  there  is  at  first  water  in  the  pleura 
with  the  air,  the  percussion  detects  the  exact  extent  of  the  liquid 
collection,  it  draws  the  line  of  demarkation  between  the  water 
and  the  air.  Whenever  the  patient  changes  his  position,  the  loca- 
tion of  the  flatness  is  likewise  changed,  and  the  metallic  tinkling 
is  heard  when  the  patient,  after  lying  in  one  position,  suddenly 
changes  it ;  so  that  the  liquid  adherent  to  the  sides  of  the  pleura 
falls  in  drops  upon  the  surface  of  the  liquid  below.  The  produc- 
tion of  this  sound,  however,  is  a  matter  concerning  which  there  is 
not  among  physicians  a  full  agreement.  There  are  according  to 
some  two  methods  by  which  it  is  produced ;  the  first  by  the  fall- 
ing of  the  liquid  drops  as  above  described,  the  second,  by  the 
passage  of  air,  which,  entering  the  liquid  in  the  pleural  sac  beneath 
its  surface,  causes,  as  it  perforates  the  surface  of  the  liquid,  little 
bubbles  to  rise,  that  burst  and  produce  the  sound.  This  bursting 
of  bubbles,  makes  a  sound,  which,  on  being  reflected  from  one 
side  of  the  cavity  to  the  other,  comes  to  the  ear  so  modified,  as  to 
produce  that  peculiar  tinkle,  which  authors  describe. 

Sometimes  this  occurs  when  there  is  no  liquid  in  the  pleural 
sac.  In  this  case  how  can  it  be  produced?  Mr.  Castelnau's  views 
will  explain  the  phenomenon.  The  metallic  tinkling,  according 
to  his  theory,  may  be  caused  by  the  bursting  of  air-bubbles  in  the 
tuberculous  abscess  itself,  just  at  or  near  the  point  of  perforation, 
and  the  sound  thus  generated  resounding  in  the  large  air-chamber 
formed  in  the  pleural  sac,  changes  a  rattle  which  would  otherwise 
be  a  mucous  rale,  into  metallic  tinkling.  The  metallic  tinkling 
is  by  no  means  a  constant  sign,  therefore  it  should  be  considered 
as  of  less  importance  than  amphoric  respiration,  and  resonance  of 
the  voice. 

To  detect  the  presence  of  liquid  in  the  pleural  sac,  the  Hippo- 


PNEUMOTHORAX.  269 

cratic  method  of  succussion  is  useful.  The  mode  of  procedure 
is  simple.  The  patient  is  placed  in  a  sitting  posture,  and  while 
the  body  is  quickly  though  moderately  shaken  by  applying  the 
hands  upon  his  shoulders,  the  agitation  of  the  fluid  thus  produced, 
is  very  clearly  heard. 

Another  morbid  sound  heard  in  this  disease,  is  the  amphoric 
respiration,  that  buzzing  sound  caused  on  blowing  into  a  bottle. 
The  cavity  of  the  pleura  may  be  compared  to  the  bottle,  arid  the 
perforation  of  the  pleura,  to  the  opening  into  it.  As  soon  as  the 
pleural  sac  becomes  somewhat  distended  with  pus,  the  amphoric 
respiration  ceases,  or  if  the  opening  is  covered  with  false  mem- 
brane, so  as  to  prevent  the  exit  of  air  from  the  cavity,  after  hav- 
ing entered  it  in  inspiration,  the  amphoric  sound  is  not  heard,  and 
there  is  either  no  morbid  sound,  or  a  slight  bronchial  respiration. 

Attendant  upon  the  amphoric  respiration  is  a  corresponding  res- 
onance of  the  voice,  which  follows  the  same  course  and  ceases 
at  the  same  time. 

As  pneumothorax  passes  into  empyema,  the  physical  signs  de- 
cline, and  there  is  then  dullness  on  percussion,  with  almost  entire 
absence  of  the  respiratory  murmur.  The  accumulation  of  pus  is 
then  much  greater  than  in  ordinary  cases  of  pleurisy,  sometimes 
amounting  to  several  gallons,  causing  extreme  difficulty  of 
breathing. 

By  the  general  symptoms  of  pneumothorax,  certainty  cannot 
be  obtained  in  diagnosis.  With  the  physical  signs,  however, 
there  is  no  difficulty  in  detecting  the  nature  of  the  lesion.  These 
are  not  only  pathognomonic  of  the  existence  of  the  disease  under 
consideration,  but  they  go  farther,  and  enable  us  to  point  out  its 
different  stages,  its  degrees  of  severity,  and  its  gradual  passage 
into  empyema. 

PROGNOSIS. — The  prognosis  is  generally  unfavorable.  In  gen- 
eral, it  is  speedily  fatal.  But  this  result  depends  as  much  upon 
the  disease  which  causes  the  pneumothorax,  as  upon  the  degree 
of  the  existing  lesion.  In  case  one  lung  is  affected  by  tubercular 
disease,  or  in  any  way  prevented  from  performing  its  functions, 
and  the  healthy  lung  is  so  perforated  as  to  produce  on  that  side, 
pneumothorax,  the  effect  is  necessarily  fatal.  In  such  a  case  the 


270 


THORACIC    DISEASES. 


patient  dies  in  a  few  hours  or  days,  from  exhaustion  and  or- 
thopnoea. 

In  forming  the  prognosis,  therefore,  the  condition  of  the  lung, 
not  the  seat  of  perforation,  should  be  made  an  object  of  special 
study.  If  one  lung  is  healthy  it  may  carry  on  the  functions  of 
both.  Whenever,  then,  we  have  one  healthy  lung  and  the  other 
is  not  the  location  of  tuberculous  disease,  the  prognosis  is  more 
favorable.  But  if  the  diseased  lung  is  tuberculous,  although  the 
other  is  comparatively  healthy,  the  probability  of  recovery  is  small, 
for  the  phthisical  disease  soon  extends  to  the  healthy  lung,  and  de- 
stroys it.  If  the  pleura  is  completely  filled  with  pus,  the  effect  is 
to  develop  hectic  fever,  and  therefore  the  physical  condition  is 
worse  than  when  the  pleural  sac  is  filled  with  air  alone.  Under 
the  most  favorable  circumstances,  we  should  consider  the  progno- 
sis uncertain,  and  in  those  cases  complicated  with  phthisis,  there 
is  no  hope  of  a  cure. 

Pneumothorax  has  no  fixed  period  of  duration.  In  a  short 
time  it  may  prove  fatal.  Dr.  Gerhard  relates  one  case  in  which 
death  took  place  in  less  than  an  hour,  and  two  other  cases  in 
which  life  was  prolonged  until  the  lapse  of  fifteen  or  eighteen 
months.  In  one  of  these  latter  cases,  the  patient  made  two  long 
voyages,  and,  according  to  his  own  statement,  did  full  duty  as  a 
seaman  while  his  pleura  was  enormously  distended  with  pus. 

TREATMENT. — The  means  which  art  is  able  to  employ  in  the 
cure  of  this  disease,  are  limited.  There  are,  however,  certain 
general  indications  to  fulfill,  a  knowledge  of  which  is  serviceable 
to  the  practitioner.  If  the  pain  is  severe  and  if  dependent  upon 
a  perforation  of  the  pleura  with  inflammation  of  that  membrane, 
local  means,  such  as  warm  fomentations,  or  sinapisms  applied  over 
the  painful  region  may  be  employed  with  advantage.  The  de- 
gree to  which  general  relaxants  should  be  carried  must  be  propor- 
tionate to  the  intensity  of  the  symptoms.  Some  preparation  of 
lobelia,  or  the  employment  of  some  other  diaphoretic  and  seda- 
tive agent  administered  according  to  the  necessities  of  the  case, 
will  be  useful  to  allay  inflammation. 

Cough  preparations  sometimes  are  useful.  In  cases  in  which 
there  is  but  little  hope  of  permanent  relief  from  medicine,  and  in 


PNEUMOTHORAX.  271 

which  other  nervines  are  not  found  sufficiently  potent  to  allay 
pain,  opiates  should  be  given  to  quiet  the  system,  and  procure 
sleep.  If  prieumothorax  caused  by  a  wound,  should  suddenly 
arise  in  a  strong  and  vigorous  constitution,  the  most  active  relax- 
ants  in  the  materia  medica  should  be  immediately  employed  in 
order  to  keep  down  the  inflammation. 

To  prevent  febrile  excitement,  and  to  promote  absorption  of 
effused  liquids,  those  means  should  be  used  which,  in  the  article 
on  Chronic  Pleuritis,  are  recommended.  To  sustain  the  strength, 
the  most  efficient  tonics  and  nutritive  diet,  should  also  be  used, 
In  case  these  do  not  have  any  good  effect  in  consequence  of  the 
disease  of  the  digestive  functions,  gentle  emetics  should  be  occa- 
sionally prescribed. 

If  remedies  fail  to  prove  at  all  salutary,  and  the  disease  should 
threaten  immediate  suffocation  from  the  quantity  of  air  and  liquids 
in  the  pleural  sac,  the  gas  and  liquid  should  be  evacuated  by  the 
operation  for  empyema.  Experience  proveSj  that,  under  certain 
circumstances,  the  opening  of  the  chest  may  be  made  with  a  good 
effect.  Successful  cases  are  reported  by  Laennec,  by  Riolan  and 
Ponteau.  In  case  the  opening  is  made  without  the  admission  of 
air,  the  disease  under  favorable  circumstances  admits  of  cure. 

[The  operation,  according  to  Dr.  Gerhard,  is  allowable  when 
the  object  is  to  favor  the  escape  of  gas,  or  the  pus  which  is  after- 
wards secreted.  Immediately  after  the  perforation  of  the  pleura, 
the  dyspnoea  may  suddenly  become  so  great  that  immediate  death 
is  to  be  feared.  The  side  may  be  punctured  in  the  usual  mari- 
ner, and  the  gas  be  allowed  to  escape ;  but,  as  in  this  case,  the 
subsequent  dangers  of  the  disease  are  certainly  increased  by  ex- 
posing the  cavity  of  the  pleura  so  freely  to  the  air,  the  operation 
cannot  be  justified  except  it  be  a  measure  of  absolute  necessity  ,J 
at  best,  it  relieves  the  patient  only  for  a  short  time.  In  the  cases 
of  advanced  empyema  which  follow  pneumothorax,  paracentesis 
may  be  performed  when  the  oppression  is  extreme,  and  the  inter- 
costal spaces  are  much  bulged  out.  The  operation  is,  however, 
very  far  from  being  devoid  of  danger ;  for  the  free  entrance  of 
the  air  into  the  cavity,  tends  to  increse  the  inflammation,  and  to 
aggravate  the  hectic  fever.  The  usual  precautions  should  be 
carefully  attended  to  after  the  operation, 


272  THORACIC    DISEASES. 

If  it  be  thought  advisable  to  perforate  the  chest,  the  best  mode 
is  perhaps  the  one  performed  by  Dr.  Bowditch  of  Boston,  who 
states  that  he  has  several  times  performed  the  operation  without 
difficulty,  or  subsequent  suffering  to  the  patient.  He  uses  a  very 
small  trocar,  and  allows  the  fluid  to  flow  through  it ;  the  instru* 
ment  is  too  small  to  allow  of  the  entrance  of  any  notable  quan- 
tity of  air,  and  in  that  manner  all  mischievous  results  from  the 
operation  are  prevented.] 


CHAPTER  XIII. 

HYDROTHORAX. 

Although  generally  applied  at  present  exclusively  to  dropsical 
collections  in  the  pleura,  the  term  hydrothorax,  may  from  its  ori- 
gin— u5wp,  water,  and  dwp«|,  chest, — be  applied  to  any  case  of 
serous  effusion  within  the  cavity  of  the  chest.  In  this  cavity 
three  kinds  of  dropsy  may  exist.  In  the  first  place,  there  may  be 
dropsy  of  the  parenchyma  of  the  lungs,  called  pulmonary  oedema ; 
secondly,  dropsy  in  the  pleural  sac,  and  thirdly,  dropsy  of  the  per- 
icardium. The  former  of  these  varieties  is  already  treated  of; 
the  latter  will  be  considered  when  I  treat  of  diseases  of  the  heart. 
Only  of  that  serous  effusion,  therefore,  which  distends  the  pleura! 
cavity,  I  shall  speak  in  this  place. 

PATHOLOGY. — The  pathology  of  the  pleural  variety  of  hydro- 
thorax,  is,  in  some  respects,  similar  to  that  of  chronic  pleurisy. 
The  liquid  effusion,  however,  is  serous  and  not  purulent.  In 
color  it  is  more  frequently  yellowish  or  brownish,  and  sometimes 
is  tinged  with  blood.  The  pleura  is  not,  in  many  cases  diseased 
and  in  this  respect,  it  differs  from  chronic  pleurisy.  It  is  apt  to 
be  associated  with  tubercles  in  their  earlier  stages  of  develop- 
ment. Like  other  forms  of  dropsy  the  effusion  often  depends 
upon  inflammation  of  the  secreting  membrane.  Some  authors 
consider  the  effusion  arising  from  this  cause  as  distinct  from 
dropsy  ;  but  they  fail  to  assign  a  good  reason  for  the  distinction. 
Whatever  is  its  origin,  when  the  effusion  is  serous  in  its  character. 


HYDROTHORAX.  273 

it  must  be  considered  dropsical.  A  very  reasonable  explanation 
of  the  phenomenon  is,  that  the  plenral  membrane  is  irritated,  arid 
that  the  congestion  of  the  blood-vessels,  is  relieved  by  the  serous 
effusion,  before  the  inflammatory  process  is  far  advanced. 

In  the  pleural  sac  more  or  less  serous  fluid  after  death  is  fre- 
quently found,  which,  during  life  had  caused  but  little  disturb- 
ance. This  may  be  the  result  of  effusion  in  the  dying  state,  or 
of  chemical  changes  occurring  after  death.  To  constitute  dropsy 
the  effusion  must  be  sufficient  to  derange  in  some  degree  the 
functions  of  life.  Whenever  existing  in  this  manner,  it  causes 
extreme  difficulty  of  breathing,  always  increased,  by  exertion,  by 
walking,  running  or  ascending  heights,  or  by  the  horizontal 
posture. 

DIAGNOSIS. —  General  symptoms.  When  the  effusion  is  small, 
the  dyspnoea  is  not  great,  but  as  fluid  collects,  the  difficulty  of 
breathing  increases.  In  general,  the  patient  lies  on  the  side  af- 
fected, and  is  most  comfortable  when  the  shoulders  and  chest  are 
elevated. 

In  the  advanced  stage  the  horizontal  position  causes  great  suf- 
focation, from  the  tendency  of  the  fluid  when  the  patient  lies 
down,  to  impede  the  pulmonary  functions.  Sometimes  placing  the 
patient,  during  a  few  moments  on  his  back,  may  cause  sudden 
death.  Preceding  such  a  result,  there  are  a  livid  or  purplish  hue 
of  the  face,  and  an  almost  black  appearance  of  the  lips,  caused 
by  a  deficient  oxydation  of  the  blood. 

In  many  cases,  it  is  associated  with  other  forms  of  dropsy. 
Anasarca,  dropsical  swelling  of  the  eye  lids,  especially  in  the 
morning,  and  in  the  evening  cedematous  swelling  of  the  feet, 
frequently  accompany  it  through  most  of  its  progressive  changes. 

Special  symptoms.  The  affected  side  is  dilated  so  much  in 
some  cases,  as  to  be  apparent  to  the  eye,  and  easily  known 
by  measurement  of  the  corresponding  parts  of  the  chest  on  oppo- 
site sides.  The  heart,  mediastinum,  diaphragm,  in  fine,  all  adja- 
cent organs,  are  more  or  less  displaced  when  the  effusion  is  very 
copious.  The  intercostal  spaces  are  bulging,  and  the  ribs  farther 
separated  than  natural.  By  succession,  a  splashing  sound  may 
sometimes  be  produced.  The  vibrations  of  the  chest  caused  by 
35 


274  THORACIC    DISEASES. 

the  voice,  over  the  side  in  which  the  effusion  exists,  are  less  easi- 
ly felt  by  the  application  of  the  hand.  Fluctuation  is  sometimes 
perceptible  on  placing  the  left  hand  on  the  chest,  and  with  the 
other  percussing  near  to  the  position  of  the  former,  and  over  an 
intercostal  space.  Bichat  considers  increased  dyspnoea  caused  by 
pressure  upon  the  abdomen,  a  useful  diagnostic  sign. 

From  chronic  pleuritis  it  may  be,  in  general,  distinguished  by 
the  absence  of  acute  pain,  and  of  the  general  and  local  signs  of 
inflammation ;  and  by  the  extreme  difficulty  of  breathing,  which 
at  times,  comes  on  in  paroxysms.  It  is  attended  by  dropsy  of 
some  other  part  of  the  system,  much  more  frequently  than 
pleuritis. 

The  physical  signs  of  hydrothorax  resemble  very  much  those 
of  effusion  from  pleuritis.  "  There  will  be  less  dullness  on  per- 
cussion, and  diminution  of  the  respiratory  murmur  in  the  depend- 
ent parts  of  the  chest ;  and  afterwards  we  have  egophony  in  the 
middle  regions ;  but  as  the  effusion  is  seldom  so  extensive  in  hy- 
drothorax as  in  pleuritis,  or  so  much  confined  to  one  side,  we  do 
not  get  that  abolition  of  the  sound  on  percussion,  and  of  the  res- 
piration and  voice,  or  the  displacements  of  organs,  or  the  peurile 
respiration  on  the  opposite  side,  which  occur  in  the  latter  disease." 

PROGNOSIS. — The  prognosis  depends  to  a  great  extent,  upon  the 
nature  of  the  exciting  cause  of  the  effusion.  If  this  can  be  re- 
moved, or  if  a  recurrence  of  the  same  causes  can  be  prevented, 
hope  of  recovery  may  be  entertained.  Spontaneous  cures  are  re- 
corded. Some  critical  evacuation  may  be  the  means  of  effecting 
a  radical  cure.  Dr.  Watson  relates  a  case  in  which  hydrothorax 
was  greatly  relieved  by  the  copions  expectoration  of  a  limpid  fluid. 
Instances  are  recorded  in  which  dropsical  effusions  have  been 
cured  by  profuse  vomiting  of  serous  matter. 

When  not  dependent  upon  tubercular  disease,  the  hope  of  a  cure 
should  be  much  greater.  If  the  pleural  sac  be  simply  distended 
by  an  infusion  caused  by  a  congested  state  of  the  pleura,  appro- 
priate treatment  will  generally  produce  recovery.  Under  more 
adverse  circumstances  remedial  agents  will  for  some  time  give  re- 
lief, so  great  and  durable,  as  to  lead  the  patient  to  hope  for  com- 
plete restoration.  But  after  the  temporary  removal  of  the  liquid,, 


HYDROTHORAX.  275 

it  continues  to  return  again  and  again,  until  the  ordinary  evacuents 
are  not  admissible  in  the  treatment  on  account  of  the  increase  of 
debility  which  they  induce.  Under  such  circumstances,  of  course, 
the  prognosis  must  be  almost  hopeless. 

TREATMENT. — In  this  disease  the  remedies  should  be  adapted  to 
the  particular  exigencies  of  each  case.  There  are,  however,  cer- 
tain general  considerations  to  which  the  practitioner  should  have 
reference  in  the  application  of  curative  agents.  In  the  first  place, 
the  object  should  be  to  correct,  as  far  as  practicable,  the  patholog- 
ical condition  on  which  the  effusion  depends.  Secondly,  to  re- 
move by  absorption  or  otherwise,  the  effusion,  by  means  which, 
while  they  attain  the  desired  object,  debilitate  but  little  the  pa- 
tient. And  thirdly,  to  support  the  strength  of  the  system,  under 
the  exhausting  influence  of  the  disease,  or  of  remedial  agents. 

The  same  remedy  sometimes  fulfills  more  than  one  of  these 
indications.  When  the  effusion  is  the  result  of  an  irritation  of 
the  pleura, — and  strong  inflammatory  symptoms  arise,  the  relax- 
ing remedies  should  be  immediately  prescribed.  Diaphoretics  and 
sudorifics,  and,  if  there  is  very  much  febrile  excitement,  emetics, 
and  the  use  of  the  vapor  bath  or  warm  bath, — all  these  means 
are  to  be  applied  as  necessity  requires. 

This  kind  of  medication  fulfills  two  indications.  It  tends  to 
remove  from  the  irritated  membrane,  by  restoring  an  equilibrium 
in  the  circulation,  the  congestion,  and  by  exciting  to  activity  those 
vessels  which  remove  from  the  system  detrita,  it  also  tends  on  the 
well  established  principle,  that  "  the  fulness  of  the  blood-vessels 
and  the  activity  of  absorption  are  in  an  inverse  ratio  to  each 
other,"  to  remove  from  the  pleural  sac,  the  serous  accumulation. 
These  means  may  be  employed  with  much  more  efficiency, 
than  the  ordinary  anti-phlogistic  treatment  which,  while  it  is  the 
cause  of  present  relief,  produces  such  an  anasmic  state,  as  to  ren- 
der the  patient  more  susceptible  to  another  attack  than  before. 
Another  advantage  arising  from  the  course  of  treatment  above  di- 
rected, is  the  fact,  that  it  prepares  the  system  for  the  application 
of  other  remedies,  and  for  the  reception  of  strength  from  the 
ready  and  good  digestion  of  food. 

To  the  side  affected  a  large  irritating  plaster  should  be  applied, 


276  THORACIC    DISEASES. 

and  kept  on  until  a  free  discharge  of  sero-purulent  matter  is  pro- 
duced. The  kind  recommended  in  the  chapter  on  pleuritis  may 
be  used.  Cathartics,  if  rightly  administered,  proper  care  being 
taken  during  their  operation,  to  keep  up  a  free  diaphoresis,  are  use- 
ful. The  following  is  perhaps  as  good  as  any  : — 

R         Podophylliae  gr.  i.  ad  gr.  ii., 

Jalapae  pulveris  gr.  x., 

Capsici  gr.  ii., 

Pottassse  bitartratis  gr.  x. 
Misce. 
Give  in  sirup  or  molasses. 

When,  instead  of  irritation  of  the  serous  tissues,  we  have  re- 
laxation or  debility  with  an  anasmic  state  of  the  blood,  or  when 
tubercular  disease  is  the  exciting  cause  of  the  pleural  irritation, 
the  treatment  must  be  modified  according  to  the  indications.  If 
the  former  condition  exists,  then  tonics  are  the  most  useful  means! 
These  should  consist  of  preparations  of  iron,  or  of  peruvian  bark. 
Five  grains  of  the  pill  of  carbonate  of  iron  of  the  U.  S.  Pharma- 
copoea,  conjoined  with  sulphate  of  quinia,  may  be  given  three  or 
four  times  per  day  ;  and  it  will  be  found  convenient  to  unite  in 
the  same  mass  some  diuretic  which  the  case  may  require ;  such 
as  squills,  or  some  other  of  which  the  dose  is  sufficiently  small  to 
admit  of  easy  combination.  To  these  means,  the  vegetable  diu- 
retics should  be  added  as  very  important  adjuncts.  Juniper,  eu- 
patorium  purpureum,  aralia  hispida,  galium  aperine,  apocynum 
androsemifolium,  and  asparagus.  The  erigeron  canadense,  a  diu- 
retic and  tonic,  is  considered  by  some,  as  preferable  to  the  above 
mentioned  articles.  "Among  the  remedies  employed,"  says  Dr. 
Wood,  "is  the  decoction  of  pipsisewa  which  is,  at  the  same  time 
mildly  tonic,  astringent,  and  diuretic,  and  is  admirably  adapted  to 
mild  cases  of  this  kind  requiring  a  gentle  impression  very 
long  continued."  Hydrastin  salicin,  apocynin  or  apocynum 
androsemifolium  are  among  the  best  tonics.  The  latter  article  is 
both  tonic  diuretic  and  laxative,  and  is,  therefore,  better  adapted 
to  these  cases  than  almost  any  other  remedy.  In  case  tonics 
cause  difficulty  of  breathing,  and  are  not  well  borne,  on  account 
of  the  inactive  state  of  the  digestive  organs,  the  most  effectual 


HYDROTHORAX.  277 

means  of  removing  the  difficulty,  is  to  give  two  or  three  times  a 
day,  alternately  with  the  tonic  remedies,  the  compound  lobelia 
pills. 

To  the  above  treatment,  the  use  of  the  vapor  bath  should  be 
added.  This  should  be  continued  until  the  extremities  become 
warm,  and  the  pulse  full,  and  strong  at  the  wrist,  and  then,  before 
its  full  relaxing  power  is  felt,  which  might  cause  too  much  debil- 
ity, the  patient  should  be  thoroughly  rubbed  by  assistants,  in  order 
to  produce  capillary  circulation.  In  case  there  is  a  deficiency  of 
biliary  secretion  attended  with  constipation  and  feeble  circulation 
of  the  blood,  I  have  found  the  folio  wing  preparation  very  useful : — 

R         Capsici 

Hydrastis  a  a  5  i. 

Fellis  inspissati  bovum  q.  s. 

Make  a  mass,  and  divide  into  four  grain  pills.  Dose, — from 
three  to  five  three  times  a  day.  In  some  cases  podophyllin  may 
be  added. 

When  there  is  no  evidence  of  excitement  and  none  of  debility 
or  anosmia,  the  remedies  should  be  directed  to  the  removal  of 
the  effused  fluid.  [For  this  purpose  no  remedies  according  to  Dr. 
Wood,  are  more  effectual  than  diuretics.  From  this  class  he  se- 
lects as  the  most  efficient,  the  bitartrate  of  potassa.  Even  when 
the  disease  is  the  effect  of  tubercular  deposits,  heu  when  the 
strength  of  the  patient  will  permit,  prescribes  this  in  small,  but 
frequent  doses,  in  order  by  its  manner  of  administration  to  secure 
a  more  potent  effect  upon  the  kidneys.  His  method  of  giving 
the  remedy  is  to  direct  a  certain  quantity  of  the  salt  to  be  added 
to  a  pint  of  water,  or  other  vehicle  in  a  bottle,  and  the  whole  to 
be  taken  in  wine-glass  doses,  at  certain  intervals  in  twenty-four 
hours ;  the  caution  always  being  observed  to  shake  well  the  bot- 
tle before  using,  and  then  to  take  the  sediment  with  the  superna- 
tant liquid.  Half  an  ounce  during  the  day  is  usually  sufficient  ; 
but  sometimes  it  will  be  necessary  to  increase  to  an  ounce,  an 
dunce  and  a  half,  or  even  two  ounces,  in  the  same  period  of  time. 
In  case  it  acts  too  much  upon  the  bowels,  it  may  be  proper  to 
check  its  action  by  astringents.  If  there  be  dyspeptic  symptoms, 
to  the  bitartrate  of  potassa  there  should  be  added  an  infusion  of 


278  THOUACIC    DISEASES. 

juniper  berries  of  wild  carrot  seed  or  some  aromatic,  as  cardamom, 
fennel  or  ginger.  By  Black-well,  squill  is  considered  as  peculiarly 
useful  in  dropsy  of  the  chest.  Beginning  with  two  or  three 
grains  three  times  a  day,  the  dose  should  be  quickly  increased, 
either  in  quantity  or  frequency  of  repetition,  until  it  produces 
nausea.  After  this  effect  is  obtained,  the  remedy  should  be  less- 
ened in  quantity  and  subsequently  kept  within  the  nauseating 
point. 

Dandelion  is  useful  when  the  dropsy  of  the  chest  is  complicated 
with  disease  of  the  liver.  Various  stimulating  diuretics  have 
been  used;  such  as  horse-radish,  mustard,  garlic,  buchu,  and 
copaiba. 

The  following  formula  for  a  stimulating  diuretic  infusion  was 
much  employed  by  the  late  Dr.  Parrish : — Take  of  juniper  ber- 
ries, mustard  seeds,  ginger  roots,  each  bruised  §  i ;  horse-radish, 
parsely-root,  each  bruised,  §  ii ;  hard  cider,  Oiv;  A  wineglassful 
to  be  taken  four  times  a  day.] 

Emetico-cathartic  remedies,  possessing  diuretic  properties,  have 
been  much  used  in  dropsy.  The  different  articles  recommended 
for  this  purpose,  are  the  bark  of  the  different  species  of  sambucus, 
the  root  of  black  elder,  the  broom(scoparus)  and  hedge-hyssop 
(gratiola  officinalis.)  The  cathartic  should  be  repeated  according 
to  the  strength  of  the  patient.  In  general  its  administration  two 
or  three  times  a  week  is  sufficiently  often  to  secure  all  the  bene- 
fit derivable  from  its  use. 

Diaphoresis,  at  present,  is  not  so  much  depended  upon  in  the 
cure  of  dropsy  as  cathartics  and  diuretics.  But,  in  hydrothorax 
caused  by  disease  of  the  lungs,  or  pleura,  it  is  of  greater  ser- 
vice than  has  been  supposed.  One  reason  why  its  use  has  been 
so  much  abandoned,  is  the  fact,  that  too  much  dependence  has 
been  placed  upon  the  common  means  of  exciting  capillary  action, 
and  when  these  means  to  a  great  extent  had  failed  of  accomplishing 
the  desired  effect,  the  conclusion  was  hastily  drawn,  that  no  rem- 
edies tending  to  produce  copious  and  long  continued  diaphoresis, 
were  of  much  utility.  The  means  upon  which  the  practitioner 
can,  with  the  most  confidence  rely  in  the  fulfilment  of  this  de- 
sign, are  the  warm  or  vapor  bath,  the  hot-air  bath,  followed  by 
the  administration  of  nauseating  doses  of  lobelia,  gradually  increased 


HYDROTHORAX.  270 

in  frequency  and  quantity,  until  emesis  is  produced.  The  gel- 
seminum,  also,  promises  to  be  a  useful  auxiliary  remedy  in  bring- 
ing about  the  same  result.  In  several  cases  I  have  succeeded  in 
effecting  diaphoresis  by  the  use  of  minute  doses  of  aconitum  fre- 
quently repeated.  The  wet  sheet,  is  also  in  many  cases  avi  easy 
and  most  effectual  means  of  producing  diaphoresis.  The  time 
and  manner  of  its  application  must  of  course  be  left  to  the  dis- 
cretion of  the  physician.  Immediately  after  the  use  of  evacuents, 
strong  tonics  should  be  given  to  prevent  a  return  of  the  effusion. 
Diet  and  drinks.  The  diet  should  be  nutritious.  That  which 
is  at  the  same  time  easily  digested,  and  which  contains  a  large 
amount  of  nutriment,  is  in  general  best  for  the  patiem.  All  un- 
necessary interference  with  the  habits  of  the  patient  should  be 
avoided.  Drinks  may  be  given  to  patients  in  this  disease  in  small 
quantities  often  repeated,  according  to  the  intensity  of  the  thirst. 
No  general  rule  can  be  laid  down  in  regard  to  the  quantity  allow- 
able. In  some  cases, -copious  drinking  of  water  or  other  liquids, 
tends  to  produce  diaphoresis,  and  thus  acts  as  a  curative  agent. 
But  it  is  in  general  best  to  be  governed  somewhat  by  the  desires 
of  the  patient ;  directing  him  to  use  such  drinks  as  tend  to  act 
either  upon  the  skin  or  kidneys.  Cold  infusions  of  diuretic  arti- 
cles, old  cider,  the  potus  imperials,*  cream  of  tartar  whey,  and 
in  some  cases  of  debility,  gin, — all  these  drinks  may  be  used  to 
quench  thirst.  For  the  same  purpose,  I  have  directed  patients  to 
drink  freely  of  Congress  water.  After  the  evacuation  of  the  flu- 
ids, if  the  patient  is  debilitated,  a  residence  near  the  sea,  and  fre- 
quent bathing  in  salt  water,  are  very  excellent  to  tone  up  the  sys- 
tem and  fortify  it  against  the  aggression  of  new  attacks.  In  one 
case  which  came  under  my  care,  and  in  which  the  use  of  di- 
uretics was  not  followed  with  very  salutary  effects,  the  frequent 
use  of  the  vapor  bath  and  mild  emetics  of  lobelia,  together  with 
hydragogue  cathartics  soon  removed  the  dropsical  effusion.  De- 
bility, remaining  a  long  time,  although  the  most  active  tonics 
were  prescribed,  I  recommended  a  residence  near  the  sea,  and  fre- 
quent bathing  in  its  water.  Improvement  immediately  com- 
menced, and  a  radical  cure  was  soon  effected.  ' 

°  Vide  mode  of  preparation,  U.  S.  Dispensatory,  p.  oG-. 


280  THORACIC    DISEASES. 

In  case  the  remedies  above  described  fail,  paracentesis  may  be 
Resorted  to  with  some  benefit,  when  there  is  reason  to  believe, 
that  the  disease  has  originated  in  mere  vascular  irritation,  or  inilam- 
mation  of  the  pleura.  In  other  cases  it  would  be  a  desperate  re- 
sort, calculated  to  afford  only  temporary  relief,  and  yet  endanger- 
ing the  life  of  the  patient  by  exciting  fatal  inflammation. 

But  when  sudden  death  threatens  from  suffocation,  the  practi- 
tioner might  perhaps  be  justified  in  resorting  to  a  temporary  ex- 
pedient. In  all  cases  it  should  be  employed  as  a  last  resort.  Di- 
rections for  the  operation  are  found  in  the  chapter  on  Chronic 
Pleurisy. 

CHAPTER  XIV. 

EMPYEMA. 

This  word  from  its  etymology  ev  in,  -ruov  pu"s,  signifies  a  collection 
of  pus  in  any  part  of  the  body.  Among  the  ancients,  however,  it 
had  a  signification  more  extensive  than  it  now  has  among  the 
moderns.  The  former  applied  it  to  those  purulent  collections 
which  form  in  the  cavities  of  the  viscera,  or  in  the  interior  of  the 
principal  organs.  The  latter  apply  the  term  empyema  to  effusions 
of  blood,  of  pus,  or  of  serum  into  the  cavities  of  the  pleurae,  as 
well  as  to  that  operation  by  means  of  which  those  liquids  are  re- 
moved from  the  interior  of  the  chest.  The  effusions  in  the  chest, 
whether  serous,  bloody  or  purulent,  are  the  results  of  diverse  dis- 
eases, of  which  the  pathology,  symptoms,  causes  and  general  prin- 
ciples of  treatment  have,  in  the  chapter  on  pleuritis,  been  consid- 
ered. I  shall,  therefore,  consider  its  diagnosis,  prognosis,  and 
some  of  the  more  specific  points  of  treatment. 

DIAGNOSIS. — The  diagnosis  of  this  disease,  by  the  ancients,  and 
the  moderns,  until  after  the  discovery  of  the  physical  signs  has 
been  considered  very  uncertain.  With  pneumonitis,  the  ancients 
confounded  it.  Its  sputum  they  described  as  "bilious,  bloody,  yel- 
lowish, viscous,  greenish  or  blackish." 

The  deficiency  of  the  common  signs  of  this  disease,  was  ac- 
knowledged by  Cullen  in  his  work  on  pneumonia.  "  Under  this 


EMPYEMA.  281 

head,  I  mean  to  comprehend  the  whole  of  the  inflammations 
affecting  cither  the  viscera  of  the  thorax,  or  the  membrane  lining 
the  interior  surface  of  that  cavity;  for  neither  do  our  diagnostics 
serve  to  ascertain  .exactly  the  seat  of  the  disease,  nor  does  the  dif- 
ference in  the  seat  of  the  disease  exhibit  any  considerable  varia- 
tion in  the  state  of  the  symptoms." 

PHYSICAL  SIGNS. — The  diagnosis  must  depend  upon  the  physi- 
cal signs ;  the  dullness  on  percussion,  the  absence  of  respiratory 
murmur  over  the  affected  side  ;  while  on  the  opposite  lung,  the 
respiration  is  more  loud,  and  somewhat  peurile  ;  the  metallic  tink- 
ling arid  amphoric  respiration  are  sometimes  heard.  Fluctuation 
caused  by  succussion  and  the  other  general  and  special  symptoms 
described  in  the  chapter  on  Chronic  Pleuritis,  are  often  present. 

PROGNOSIS. — In  the  majority  of  cases,  this  is  unfavorable. 
The  character  of  the  effused  fluid,  the  constitutional  disturbance, 
the  degree  of  strength,  and  condition  of  the  lung  opposite  the  dis- 
eased one,  should  be  considered  in  forming  the  prognosis.  Some- 
times, the  pus  spontaneously  perforates  the  parietes  of  the  chest, 
and  is  discharged  during  a  long  time.  The  cases  of  recovery  are 
rare.  But  sometimes  they  occur,  and  therefore,  some  hope  may 
be  entertained  of  relief  and  cure  either  spontaneously  or  from  an 
operation. 

TREATMENT. — In  case  the  spontaneous  discharge  of  pus  is  great, 
and  the  system  shows  signs  of  depression,  means  should  be  used 
to  keep  up  the  strength.  For  this  purpose  nourishing  diet  and  the 
strongest  tonics  should  be  used.  If  there  is  a  purulent  expectora- 
tion, this  should  be  promoted  by  expectorants,  and  if  there  is  evi- 
dence that  the  digestive  organs  suffer  from  any  collection  of  mor- 
bid matter,  an  emetic  adapted  in  thoroughness  or  mildness  to  the 
exigencies  of  the  case  should  be  administered.  In  all  cases  in 
which  purulent  or  sero-purulent  matter  is  absorbed  in  large  quan- 
tities into  the  blood,  the  emunctories  should  be  stimulated  to  ac- 
tion. This  effect  is  produced  by  the  use  of  the  vapor  bath. 
In  caso  there  is  not  much  febrile  excitement,  alcoholic  drinks  when 
combined  with  tonics,  expectorants,  and  nourishing  food,  are  not 
36 


282  THORACIC    DISEASES. 

inadmissible.  Pure  wine,  porter,  or  ale,  and  if  the  kidneys  are 
inactive,  gin  may  be  given  to  keep  up  the  strength  of  the  system, 
while  the  suppurative  process  is  going  on.  These  last  means  are 
most  serviceable,  when  the  empyema  is  the  result  of  tuberculosis. 
In  such  cases,  even  when  the  hectic  fever  is  considerable,  their 
use  may  be  persevered  in.  If,  however,  there  be  fear  of  produc- 
ing over-excitement,  alternately  with  the  administration  of  alco- 
holic stimulants,  a  pill  of  extract  of  lobelia,  or  some  other  relax- 
ing and  sedative  agent  should  be  given. 

Mr.  MacDonnell  has  written  an  interesting  article  on  empyema, 
in  which  he  relates  several  cases  wherein  tumors  appeared  on  the 
surface  of  the  chest.  These  were  red,  tense,  pulsating,  and  shin- 
ing. At  length  they  burst,  giving  exit  to  a  large  quantity  of  pus. 
The  empyema  attended  with  these  pulsating  tumors,  he  calls 
the  Pulsating  Empyema  of  Necessity. 

Mr.  MacDonnell  relates  several  cases  of  much  interest.  In  one 
of  them,  two  tumors  appeared  on  the  left  side,  one  near  the  spot 
occupied  by  the  apex  of  the  heart,  the  other  between  the  tenth 
and  eleventh  ribs  near  the  spine.  The  opening  of  the  tumors 
gave  relief,  but  the  patient  subsequently  died  of  phthisis.  In 
another  case,  two  tumors,  each  about  the  size  of  a  hen's  egg 
were  observed,  one  just  below  the  nipple,  the  other  between  the 
tenth'  and  eleventh  ribs,  about  two  inches  from  the  spinal  column. 
These  tumors  were  rather  tender  to  the  touch,  a  few  turgid  veins 
surrounded  their  bases,  the  integument  covering  them  was  discol- 
ored, and  reddish,  and  they  both  possessed  a  well-marked  fluctua- 
tion, and  a  distinct,  perceptible,  and  diastolic  pulsation.  Other 
cases  of  a  similar  nature  are  related  by  Mr.  MacDonnell.  In  one 
case  of  empyema,  the  pus  made  its  way  into  the  bronchial  tubes, 
and  was  removed  by  expectoration. 

These  tumors  arising  from  the  "  Pulsating  Empyema  of  Nec- 
essity^ may  be  distinguished  from  Thoracic  aneurism,  by  (a), 
The  history  of  the  case,  (b),  The  dullness  extending  over  the 
whole  side,  the  pulsation  being  felt  only  in  the  external  tumor,  (c), 
The  absence  of  thrill,  (d),  The  absence  of  bruit  of  soufflet.  (e), 
The  extent  and  nature  of  the  fluctuation.  Froniencephaloid  dis- 
ease of  the  lungs  and  mediastinum,  by  (a),  The  absence  of  ex- 
pectoration resembling  black  currant  jelly,  (b),  The  absence  of 


PHTHISIS.  283 

persistent  bronchitis.  Such  cases  as  above  described  are  not  often 
found.  Occasionally  they  may  supervene  in  consequence  of  badly 
treated  acute  pleuritis.  •  I  have  seen  one  case  similar  to  those  de- 
scribed by  Mr.  MacDonnell.  The  fistulous  opening  was  upon  the 
left  side  of  the  spine,  about  an  inch  exterior,  and  between  the 
tenth  and  eleventh  ribs.  From  a  gill  to  a  pint  of  pus  was  dis- 
charged daily  for  about  a  month,  gradually  diminishing  in  quan- 
tity, until  at  the  end  of  three  months  it  ceased.  By  the  use  of 
mild  emetics  and  tonics,  of  which  the  wild  cherry,  and  sirup  of 
the  iodide  of  iron  were  the  most  important,  a  comfortable  degree 
of  health  was  obtained.  The  affected  side  was  left  permanently 
contracted.  Empyema  has  a  peculiar  effect  upon  the  functions  of 
the  liver.  This  organ  is  enlarged  from  an  engorgement  with 
blood.  This  enlargement  is  evidently  identical  with  that  which 
takes  place  in  other  affections  of  the  lungs  and  heart,  where,  in 
consequence  of  the  partial  suspension  of  their  functions,  an  addi- 
tional amount  of  labor  is  thrown  upon  the  liver.  The  removal 
of  this  enlargement  is  one  of  the  first  signs  which  indicate  the 
subsidence  of  the  effusion,  and  the  return  of  the  compressed  lung 
to  the  performance  of  its  normal  functions. 


CHAPTER  XV. 

PHTHISIS. 

The  word  phthisis,  from  the  Greek  <pdi;w  to  waste  away1,  signi- 
fies a  gradual  decay  of  the  body.  By  this  term  is  meant  a  state 
of  continued  and  slow  consumption,  not  exclusively  of  any  one 
part,  but  of  the  general  system.  It  is  a  generic  term,  applying 
equally  well  to  organic  changes  in  the  various  organs  of  the  body. 
Such  specific  terms  to  the  generic,  are  appended  as  most  definite- 
ly indicate  the  location  of  the  disease.  Accordingly  we  hava 
laryngeal,  pulmonary,  intestinal  or  mesenteric,  hepatic  and  gastric 
consumption,  described  by  authors.  These  distinctions  are  some- 
what arbitrary ;  all  kinds  of  consumption  being  a  constitutional 
rather  than  a  purely  local  affection. 

The  term  pulmonary  is  used  to  denote  a  decay  of  the  lungs ; 


284  THORACIC    DISEASES. 

but  since  other  diseases  produce  this  effect,  it  is  necessary  to  re- 
strict its  application  to  those  cases  in  which  tubercles  are  the  ex- 
citing cause  of  the  disease.  This  definition  being  adopted  a 
decay  of  the  lungs  arising  from  bronchitis  or  pleuritis,  uncompli- 
cated with  tuberculous  deposition,  cannot  properly  be  considered 
consumption. 

Tuberculous  phthisis  as  thus  defined  is  by  far  the  most  formid- 
able disease  of  the  thorax.  No  other  is  so  sure  to  terminate  the 
lives  of  its  victims,  and  so  little  under  the  control  of  medication. 


SECTION    I. 
TUBERCLES. 

PATHOLOGY. — The  pathology  of  phthisis  was  but  imperfectly 
understood  by  the  ancients.  Of  its  nature  the  Grecian  Father  of 
Medicine,  Hippocrates,  had  no  accurate  knowledge.  He  recog- 
nized the  existence  of  tubercles,  and  attributed  their  cause  to  pet- 
rified phlegm.  With  this  error  of  Hippocrates,  Galen  associated 
the  idea  that  they  were  caused  by  the  descent  of  humors  from 
the  head,  or  by  the  putrefaction  of  effused  blood.  To  Sylvius, 
whose  works  were  published  in  1679,  belongs  the  honor  of  first 
giving  a  scientific  explanation  of  their  nature  and  origin.  With 
scrofula  he  showed  their  connection,  of  phthisis  he  considered 
them  the  cause.  To  the  degeneration  of  certain  invisible  glands 
in  the  lungs,  he  attributed  their  rise.  By  his  successors,  by  Mor- 
ton and  Broussais  his  opinions  were  adopted.  In  1733  Desault 
revealed  to  the  world  the  result  of  thirty-six  years  of  investiga- 
tion into  the  nature  and  causes  of  consumption.  His  view,  that 
it  was  dependent  upon  the  formation  of  tubercles,  was  enter- 
tained by  Russel  Halles,  Gilchirst  and  Mudge.  By  the  more  re- 
cent researches  and  investigations  of  Stark,  Bayle,  Laennec,  Louis, 
Andral  and  Carswell,  the  anatomy  of  tubercles  and  their  course  of 
development,  is  now  rendered  more  accurate  and  complete  than 
that  of  any  other  morbid  product.  And  yet  diverse  opinions  re- 
specting their  nature  and  development  still  prevail ;  and  doubtless 
that  diversity  will  still  exist  until  chemistry  shall  have  attained 


PHTHISIS.  285 

an  ultimatum,  until   optics  shall  have  reached   that  limit    beyond 
which  art  and  science  can  never  pass. 

At  present,  the  more  general  opinion  is,  that  consumption  is  a 
constitutional  disease,  most  often  producing  its  greatest  lesions  in 
the  chest.  The  essential  character  of  pulmonary  consumption, 
consists  in  the  deposit  of  tubercles  in  the  tissues  of  the  lungs. 
This  deposit  may  begin  with  local  mischief,  or  may  evidently  be 
a  sequel  of  constitutional  disorder.  In  both  varieties  the  general 
disease  is  present;  although  it  may  exist  in  a  latent  form.  Of 
this,  the  formation  of  tuberculous  matter  is  a  proof.  It  is  evi- 
dent, however,  that  the  presence  of  tubercles  does  not  alone  con- 
stitute the  disease.  One  step  back,  along  the  chain  of  causation 
is  a  morbid  condition,  of  which  tubercles  are  but  the  effect. 
This  morbid  condition,  whatever  is  its  nature,  may  exist  a  long 
time,  before  the  deposit  of  tubercle  begins. 

That  a  change  takes  place  in  the  blood,  which  causes  or  pre- 
cedes the  deposit  and  development  of  tubercles,  is  well  established. 
The  corpuscles  are  diminished  and  the  albumen  increased  in  quan- 
tity. The  fibrin  is  below  rather  than  above  the  normal  amount, 
and,  it  may  be  inferred,  that  it  is  also  defective  in  its  nature. 
Eisner,  and  some  other  analysts,  have  found  the  fatty  principles 
diminished.  Dr.  Tricke's  analyses  indicate  an  increase,  above  the 
standard  of  health,  in  the  lime  and  a  decrease  in  the  phosphates; 
while  1'Hcriticr  states,  that  in  scrofula,  the  earthy  salts  are  di- 
minished. Heuce,  the  blood  may  be  stated  generally  to  be  de- 
graded in  quality,  and  endowed  with  a  low  degree  of  vitality. 
Whether  these  be  the  real  changes  in  the  blood  is  not  certainly 
determined.  Physiologists  and  pathologists  arc  not  fully  agreed 
as  to  the  nature  of  all  the  changes  through  which  the  blood  passes, 
in  the  scrofulous  diathesis.  Andral  showed  that  in  phthisis  pul- 
monalis,  the  fibrin  was  augmented.  The  probability  is,  that  this 
increase  of  fibrin  is  most  frequent  when  intercurrent  pneumonitis 
is  associated  with  the  tubercular  disease.  To  attain  to  accuracy 
in  this  matter  is  very  difficult,  on  account  of  the  variable  state  of 
the  blood  arising  from  diet,  exercise,  time  of  the  day,  and  other 
changing  circumstances. 

Some  general  results  of  agreement,  however,  are   established. 
These  prove  without  doubt,  that  the  blood  corpuscles  and  fatty 


286  THORACIC    DISEASES. 

principles  are  diminished  in  quantity,  whilst  the  albumen  is  com- 
paratively augmented, — a  change  which  seems  well  proved  by  all 
the  chemical,  physiological  and  pathological  researches  with  which 
we  are  acquainted.  Such  a  condition  of  the  blood  of  course, 
causes  a  deviation  from  the  perfect  physiological  standard  of  the 
corporeal  functions.  The  symptoms,  indicating  the  existence  of 
such  a  state,  are  constitutional  debility,  from  a  deficiency  of  nutri- 
tion. Hence  the  waste  which  takes  place  in  the  colored  corpus- 
cles, and  in  the  muscles  and  other  tissues. 

[The  conclusions  to  which  we  may  logically  come  are  the  fol- 
lowing:— 1,  That  from  the  earliest  invasion,  the  sum  of  the  vital 
force  is  either  below  the  standard  of  health,  or  it  is  relatively  low 
as  respects  the  structure  and  organization  of  the  individual  ; — 2, 
That  this  diminution  in  the  sum  of  vital  force,  is  dependent  on 
the  imperfect  blastema  of  the  diseased  blood  causing  perversion 
of  the  tissues ; — 3,  That  as  tuberculosis  advances,  the  sum  of  the 
vital  force  for  the  whole  system  continues  to  diminish ; — 4,  That 
the  nutritive  powers  of  the  blood,  as  respects  the  nervous  tissue, 
frequently  remains  undiminished,  this  tissue  not  requiring  for  its 
nutrition,  compound  principles  identical  with  it  to  be  introduced 
into  the  blood  with  the  food,  and  having  a  nutrition  peculiar  to 
itself,  differing  from  that  of  the  cellular  and  muscular  structures. 

The  fatal  disease,  tuberculosis  may  be  traced  to  a  primary  error 
or  defect  in  the  blood-making  process.  Vitiated  air,  or  air  stag- 
nating or  .insufficiently  renewed  within  the  chest;  and  probably 
other  anti-hygienic  influences,  as  a  vitiated  or  defective  diet,  act- 
ing singly,  coetaneously,  or  as  respects  each  other  ancillary,  pro- 
duces, slowly  under  ordinary  circumstances,  but  occasionally  with 
great  rapidity,  some  unknown  change  in  a  portion  of  the  protein- 
iform  principle  of  recently  formed  liquor  sanguinis ;  this  change 
may  consist  in  hyper-oxydation,  but  whether  so  or  not.  it  deterior- 
ates its  properties,  rendering  it  more  or  less  or  altogether  unsuita- 
ble as  a  material  for  organization. 

At  the  same  time,  the  oily  principle  of  nutrition,  circulating 
with  a  diminished  number  of  red  corpuscles,  is,  in  part,  converted 
into  a  fatty  substance  of  a  lower  degree  of  oxydation.  These 
modified  proteiniform  and  oleaginous  principles  are  exuded  in  the 
blastema,  and  are  either  employed  in  the  assimilating  processes, 


PHTHISIS.  287 

deranging  the  nutrition  of  many  of  the  organic  structures,  and 
giving  the  tuberculous  or  scrofulous  character  to  various  patholog- 
ical processes ;  or,  in  the  more  advanced  stage  of  the  morbid 
process,  they  are  deposited  in  particular  tissues,  and  accumulate, 
generally  in  the  form  of  tubercle,  but  sometimes  both  as  tubercle 
and  morbid  fat ;  substances,  for  the  most  part,  incapable  of  organ- 
ization. In  the  present  state  of  pathological  science,  confining 
ourselves  to  its  legitimate  object,  the  study  of  phenomena,  apart 
from  any  metaphysical  views  of  final  causes  relating  to  the  powers 
of  nature,  this  appears  to  be  the  most  accurate  definition  that 
can  be  given  of  the  most  essential  nature  of  tuberculosis.-  [Dr. 
Ancell.j 

Though  we  no  longer  believe  in  the  elements  of  Thalcs,  we 
may,  without  a  great  stretch  of  the  laws  of  the  natural  sciences, 
admit  that  air  is  the  chief  element  of  health  or  disease,  according 
as  it  is  supplied  to  the  lungs  in  its  unadulterated  condition  of  four- 
fifths  nitrogen,  and  one-fifth  oxygen,  or  as  it  carries,  diffused 
through  it,  carbonic  acid  gas,  carbonated  hydrogen,  sulphureted 
hydrogen,  the  effluvia  of  cess-pools  and  drains,  the  poison  of  in- 
fluenza or  cholera,  the  emulations  of  the  variolous  or  typhus 
patient. 

But  in  what  manner  does  the  deposit  take  place  ?  We  possess 
sufficient  evidence  to  show  that  it  is  derived  from  the  blood  ;  that 
it  transudes  from  the  capillary  vessels  of  the  part  in  which  we 
find  it ;  and  that,  after  having  been  deposited,  it  is  liable  to  un- 
dergo certain  further  changes.  On  a  close  examination  of  incipi- 
ent tubercular  deposit,  we  may  always  note  that  there  is  conges- 
tion in  the  tissues  immediately  surrounding  it.  In  the  pia-mater 
of  the  sylviau  fissure,  we  see  an  increased  redness  in  which  a  few 
vessels  arc  more  prominent  than  usual ;  in  the  pulmonary  paren- 
chyma we  may,  especially,  by  the  use  of  the  microscope,  discover 
the  engorgement  of  the  interlobular  capillaries  investing  the  air 
vesicle  into  which  the  tubercle  is  being  secreted  ;  in  the  mucous 
membrane  of  the  intestines,  we  see  the  exquisite  arborescent  ar- 
rangement of  the  congested  vessels,  tending  from  the  mesenteric 
attachment  to  the  point  where  we  observe  the  deposit,  shining 
through  the  mucous  surface  from  the  sub-mucous  tissue  in  which 
it  has  collected.  The  first  elimination  of  the  morbid  products 


288  THORACIC    DISEASES. 

acts  like  a  magnetic  point  of  attraction,  and  generally  serves  as  a 
centre  around  which  the  deposit  progressively  enlarges  by  eccen- 
tric deposition. 

The  amount  of  vesicular  action  accompanying  the  elimination, 
varies  in  different  individuals ;  in  some  there  is  scarcely  a  percep- 
tible increase  in  the  sanguinous  current,  in  others,  we  cannot  deny 
the  presence  of  acute  inflammation,  shown  both  by  the  congested 
state. of  the  blood-vessels,  and  by  the  presence  of  plastic  exuda- 
tion, and  exudation  corpuscles.  In  ordinary  inflammatory  condi- 
tions, we  may  actually  observe  the  part  taken  by  the  capillary 
vessels  in  the  process  of  transudation.  We*  see  the  inflammatory 
product  immediately  after  its  passage  through  the  vesicular  mem- 
brane, coating  the  vessels ;  and,  we  may  see  the  same  matter 
within  the  vessels  adhering  to  the  coats  previous  to  its  discharge. 

Whether  it  be  so  or  not,  whether  we  may  be  enabled  to  observe 
the  transition  of  the  contents  of  the  vessels  into  the  surrounding 
parts  or  not,  it  is  "evident  that  we  ought  not  to  be  satisfied  with 
ascertaining  the  fact  of  the  exudation  as  the  primary  change. 
We  are  driven  to  take  one  step  more,  before  we  gain  the  fountain- 
head  of  the  malady ;  we  therefore  look  to  the  constitution  of  the 
blood  itself  in  tubercular  disease,  in  order  to  ascertain  whether 
any  deficiency  in  the  normal  components,  any  variation  in  their 
relative  amount,  any  new  products  are  to  be  met  with,  which 
may  explain  the  source  of  the  extravascular  deposit.  All  observ- 
ers, who  have  brought  either  the  microscope  or  chemical  analysis 
to  bear  on  this  subject,  are  agreed,  that  there  is  an  alteration  in. 
the  blood,  indicating  a  want  of  vigor  and  tone.  [Dr.  Sieveking.j 

This  abnormal  condition  of  the  blood,  to  a  limited  extent,  is 
doubtless,  the  predisposition  to  phthisis  of  which  authors  speak. 
Consonant  with  this  opinion  Mr.  Ancell,  in  his  work  on  "  Tuber- 
culosis," remarks  : — "  The  predisposition  differs  from  the  general 
disease  only  in  degree,  and  the  condition  of  the  blood  in  the  pre- 
disposition is  the  same,  differing  only  in  degree." 

But  one  thing  more  is  wanting  in  order  to  the  attainment  of 
any  practical  result.  We  want  a  positive  and  conclusive  sign  by 
which  the  predisposition  may  be  recognised.  Such  an  indication 
of  this  incipient  condition  of  tuberculosis  would  be  of  extreme 
value  ;  for,  as  the  diagnosis  of  diseases  of  the  thorax  has  improved, 


289 

•our  treatment  of  these  diseases  has  commensurately  acquired 
greater  simplicity  and  certainty.  Although,  in  the  opinion  of 
some,  the  organs  of  oxygenation  have  a  greater  share  in  its  devel- 
opment, than  other  organs,  yet  the  stomach  is  no  doubt  a  promin- 
ent agent  in  the  production  of  phthisis.  Whenever  this  organ,  in 
consequence  of  debility  or  any  abnormal  change,  does  not  prop- 
erly furnish  nutriment  to  the  blood  through  the  digestive  process, 
a  reduction  of  vitality  must  be  the  consequence. 

Baudelocque,  however,  shows  a  very  intimate  connection, — as 
cause  and  effect, — between  the  results  of  vitiated  air  and 
scrofulous  disease.  But  notwithstanding  this,  we  must  from  rea- 
son as  well  as  from  experience,  conclude,  that  the  effect  of  vitia- 
ted air  upon  the  respiratory  organs  and  through  them  on  the 
blood,  acting  coetaneously  with  the  effect  of  dyspeptic  disease  of 
the  stomach  upon  the  blood,  is  much  more  sure  to  produce  tuber- 
culosis than  when  the  stomach  is  in  a  healthy  condition. 

The  illustrations  used  by  Baudelocque,  to  show  the  tendency 
of  impure  air  to  develop  tubercles,  are  forcible  and  convincing. 
Speaking  of  the  shepherds  of  his  country,  who,  for  the  most  part, 
lead  an  open-air  life,  he  says,  that  in  them  the  cause  of  the  dis- 
ease is  their  habit  of  sleeping  six  or  eight  hours  in  confined  huts 
which  they  transport  with  them,  having  only  a  small  door,  that 
they  close  when  they  enter,  and  keep  closed  during  the  day.  A 
similar  injurious  effect  is  produced  by  the  habit  of  sleeping  with 
the  head  under  the  clothes,  and  the  insalubrity  of  school  rooms 
in  which  a  number  of  children  are  assembled  together.  These 
causes  frequently  repeated,  are  prolific  in  the  development  of  any 
latent  germs  of  phthisis  which  may  be  existing  in  the  blood. 

Close  rooms,  Dr.  Arnott  has  pithily  remarked,  "  act  like  extin- 
guishers to  the  vital  flame  ;  and  the  extinction  literally  takes  place 
at  the  point  at  which  the  fuel  accumulates  for  want  of  being 
burnt  off." 

Since  the  blood  is  the  true  source  of  the  tubercular  deposit,  it 
is  not  surprising  that  all  the  organs  of  the  body  are  more  or  less 
liable  to  become  the  seat  of  the  morbid  product.  Some  tissues 
present  a  greater  proclivity  to  the  deposition  than  others;  and 
some,  as  the  fibrous  and  tegumentary  tissues,  appear  to  enjoy  al- 
most an  immunity  from  tubercle.  At  the  two  ends  of  the  scale, 
37 


290  THORACIC    DISEASES. 

we  may  place  the  mucous  membranes  and  fibrous  tissues ;  the 
former  are  the  native  soil  for  this  tree  of  death ;  the  latter  are 
rarely,  if  ever  affected.  There  can  be  little  doubt,  that  this  de- 
pends, in  a  measure,  upon  certain  physical  laws,  influencing  the 
current  in  the  vascular  system,  and  determining  the  greater  or  less 
facility  of  transudation  in  the  first  instance. 

To  show  that  the  deposit  of  tubercle  is  in  the  mucous  mem- 
brane of  the  lungs,  is  more  difficult  than  to  show  its  location  in 
the  mucous  membrane  of  the  fallopian  tubes  and  uterus,  because 
these  latter  organs,  on  their  internal  surface,  are  lined  with  mucous 
membrane,  so  abundant  as  to  be  easily  recognised.  The  more 
slow  and  the  more  free  from  complication,  the  tubercular  disease 
of  the  lungs  is,  in  its  nature,  so  much  the  more  readily  may  be 
detected  the  disease  of  the  mucous  membrane,  and  the  tubercu- 
lous deposit  in  it. 

Dilatation  of  the  air-cells  in  emphysema  has  enabled  Dr.  Alison 
to  distinctly  perceive  the  tuberculous  matter  contained  in  these 
cells.  [Edin.  Medi-Chro.  Trans,  vol.  i.  p.  427.] 

[Dr.  Sieveking  observes, — "that  we  may  lay  it  down  as  a  law, 
regulating  the  deposit  of  tubercle,  that  it  is  effected  at  that  point 
of  an  organ  or  of  a  tissue  where  the  smallest  amount  of  pressure 
is  exerted  upon  the  capillary  system.  This  does  riot  exclude  the 
operation  of  other  laws  which  determine  the  attraction  to  any  one 
organ.  It  does  not  offer  any  reason  why  in  one  case  we  find  tu- 
bercle in  the  spleen,  in  another  in  the  mesenteric  or  bronchial 
glands,  in  a  third  exclusively  in  the  pulmonary  tissues;  but  it 
seems  to  embrace  the  various  circumstances  modifying  the  exact 
site  of  the  deposit  in  these  different  parts  of  the  system.  The 
vis  a  tergo  varies  but  little  in  the  different  parts  of  the  capillary 
system;  but  the  relation  to  surrounding  tissues  differs  very  much. 
Thus,  while  the  force  with  which  the  blood  is  driven  into  the  in- 
terlobular  plexuses  of  the  lungs  is  identical,  the  pressure  which  the 
respective  capillary  systems  meet  with  in  a  case  of  congestion, 
which  implies  a  tendency  to  exudation,  is  necessarily  greater  in 
the  bone  than  in  the  soft  parenchymatous  structure.  No  organ  is 
more  frequently  the  seat  of  tuberculous  deposit  than  the  lung, 
and  in  none  do  we  find  the  capillary  ramifications  of  the  vessels 
with  so  little  covering.  They  almost  lie  naked  on  the  surface. 


PHTHISIS.  '/iyJ 

Beyond  the  basement  membrane  forming  air  vesicles,  and  possi- 
bly a  delicate  epithelial  layer,  there  is  nothing  between  the  capil- 
lary net-work  and  the  atmosphere.  We  need  not,  therefore,  won- 
der that  the  ultimate  vesicle,  in  which  the  bronchi  terminate, 
is  above  all  other  points,  that  of  tuberculous  election.  The  re- 
cepticle  is  ready,  the  product  being  in  the  blood,  a  slight  increase 
of  pressure  will  overbalance  the  natural  and  healthy  equilibrium 
between  the  external  and  the  internal  fluids,  and  the  discharge 
takes  place. 

[f  this  view  is  correct,  nothing  but  a  previous  change  in  the  ul- 
timate vesicles,  or  bronchules  could  give  rise  to  a  deposit  of  tuber- 
culous matter  in  the  intervesicular  tissue,  in  the  parenchyma  of 
the  lung  itself,  as  contradistinguished  from  the  respiratory  cavi- 
ties. We  can  suppose  that  obliteration  of  a  portion  of  the  breath- 
ing apparatus  might  leave  the  intervesicular  texture  less  resistent 
than  the  air  vesicles ;  and,  in  that  case,  we  should  expect  to  find 
an  interstitial  deposit.  Whether  this  does  actually  occur,  I  am 
not  prepared  to  say.  I  have  not  seen  any  appearances  that  would 
justify  the  assumption  of  a  primary  interstitial  deposit,  but  I  have 
seen  a  distinct  deposit  of  tuberculous  matter  within  the  air- vesi- 
cles, and  I  have  traced  its  primary  deposit  in  the  semi-liquid  form, 
in  the  solitary  vesicle,  to  the  deposit  in  numerous  adjoining  vessels, 
causing  destruction  of  their  breathing  power  and  obliteration  of 
the  bronchule  terminating  in  them.  The  ultimate  bronchule  is 
free  and  patulous,  and  the  tuberculous  matter  fills  the  vesicle  as  a 
bullet  fills  its  mould. 

The  law,  that  the  tendency  to  the  deposit  in  an  organ,  is  in- 
versely as  the  pressure  the  vessels  sustain,  or  that  it  is  in  the  ratio 
of  the  laxity  of  the  tissues,  is  supported  by  the  views  which  are 
commonly  held  with  regard  to  the  chemical  constitution  of  tuber- 
cle. This  law,  also  assists  us  in  explaining,  why  certain  parts  of 
different  organs  possess  so  marked  liability  to  become  the  seat  of 
tuberculous  exudation.  This  feature  constitutes  an  essential  dif- 
ference between  tubercle  as  a  mere  effusion  of  a  certain  constitu- 
ent of  the  blood,  and  those  other  new  formations  in  which  we 
cannot  but  see  a  tendency  to  independent  development,  or  organ- 
ization. The  most  familiar  instances  of  pathological  processes 
with  which  it  may  be  compared,  are  the  serous  effusions,  that 


292  THOKACIC    DISEASES. 

take  place  into  the  peritoneal  cavity,  from  obstruction  to  the  vena 
eava  or  portal  system,  inducing  congestion  and  consequent  liquid 
discharge  at  the  most  yielding  points. 

If  we  adopt  this  view  of  the  subject,  it  appears  to  offer  an  ex- 
planation of  the  circumstances  that  the  apices  of  both  lungs  are 
the  chief  seats  of  tubercle,  while  it  tends  to  show  the  importance 
of  encouraging  the  u*se  of  all  the  physical  means  at  our  com- 
mand to  promote  a  free  and  active  circulation  of  the  entire  vascu- 
lar current,  and  to  obviate  and  anticipate  anything  approaching  to 
local  congestion  in  the  organs  and  parts  of  organs  which  we  know 
to  be  most  liable,  at  different  periods  of  life,  and  under  different 
circumstances,  to  become  affected  with  the  disease  in  question. 

The  manner  in  which  the  law  may  be  applied  to  the  explana- 
tion of  the  predominant  proclivity  of  the  pulmonary  apices,  is 
simply  this  : — The  upper  portions  of  both  lungs  are  surrounded 
by  more  unyielding  parietesthan  the  inferior,  they  have  less  room 
for  expansion ;  consequently,  if  there  is  any  increase  in  the  vas- 
cular current  supplying  these  parts,  the  difference  between  the 
pressure  of  the  parietes  and  of  the  atmosphere  within  the  vesicles 
will  increase  unduly,  and  effusion  will  take  place  into  the  latter. 
In  acute  tuberculosis,  we  do  not  observe  this  peculiar  election, 
because  the  process  is  of  a  more  active  character ;  the  strain  upon 
the  capillaries  of  the  entire  organ  is  greater  than  they  can  bear, 
and  we  consequently  find  the  deposit  takes  place  with  much  uni- 
formity throughout  the  lung. 

In  chronic  forms  in  which  tuberculous  deposit  generally  occurs, 
the  balance  of  the  forces  in  different  parts  of  the  vascular  system, 
is  in  a  measure  preserved,  and  only  the  very  weak  points  are  as- 
sailed. There  may  be  other  forces  which  come  into  play ;  there 
may  be  elective  affinities  between  different  tissues,  and  morbid 
products  with  which  we  are  as  yet  not  even  acquainted.  The 
circumstance  above  alluded  to,  is  one  of  some  importance.  In 
scrofulous  deposit  in  the  kidneys  where  does  the  tuberculous  mat- 
ter invariably  present  itself?  In  the  loose  texture  of  the  cortical 
substance.  The  dense  basement  membrane  and  firmer  epithelial 
coat,  wards  off  the  encroachment ;  but  the  feebler  texture  of  the 
convoluted  tubes  is  unable  to  repel  the  enemy.]  Another  cause  of 
the  more  frequent  location  of  tubercles  in  the  superior  lobes  of 


PHTHISIS.  293 

the  lungs,  has  been  suggested,  which  seems  somewhat  plausible, 
and  is  a  useful  hint  to  the  treatment  required  in  tuberculosis. 
The  increased  motion  of  the  lower  lobes  of  the  lungs,  would 
cause  a  more  ready  expulsion  from  the  vesicles  of  tuberculous  de- 
posits, than  would  take  place  in  the  apices.  In  the  vesicles  of  the 
apices,  on  account  of  their  want  of  expansion,  there  would  evi- 
dently be  a  tendency  to  accumulation,  while  in  other  parts  of  the 
pulmonary  tissue  the  reverse  would  be  true.  So  that,  on  this 
hypothesis,  there  might  be  an  equal  amount  of  tuberculous  mat- 
ter exuded  into  the  vesicles  in  all  parts  of  the  lungs,  and  yet,  on 
account  of  its  more  ready  expulsion  from  one  part  of  the  lung 
than  from  another,  the  development  of  tubercles,  as  experience 
verifies,  be  most  active  in  the  apices. 

"  Tubercles  exist  in  various  forms  ;  in  fine  points,  gray  and  yel- 
low granulations,  miliary  tubercles;  and  gray  or  yelLow  tubercu- 
lar masses,  softened  and  cretaceous.  Each  of  these  modifications 
requires  a  more  particular  notice. 

"1.  Pulmonary  Granulations. —  Gray  Granulations. — Miliary 
Tubercles. — These  various  names,  have  been  used  by  authors  to 
describe  round,  small,  translucent,  shining,  homogenous  bodies, 
often  not  larger  than  a  millet  seed,  but  varying  from  this  size  to 
that  of  a  pea,  which  appear  to  be  the  primitive  state  of  tubercles. 
Usually  they  are  of  a  grayish,  but  often  of  a  reddish,  or  of  a  brown- 
ish color;  and  in  some  cases  they  are  nearly  colorless.  Some- 
times they  are  isolated,  sometimes  clustered  in  small  bunches,  or 
in  aggregate  masses.  In  the  latter  state  they  are  most  often  found 
in  the  upper  portions  of  the  lung.  But  in  an  isolated  form  they 
are  sometimes  scattered  thickly  throughout  the  whole  or  greater 
portion  of  the  pulmonary  tissue  ;  not  unfrequently  they  are  found 
situated  beneath  the  pleura,  producing  an  irregularity  perceptible 
to  the  touch.  This  is  more  often  the  case  in  children  than  in 
adults. 

"2.  Gray  Tubercular  Infiltration. — Laennec  defines  this  as  the 
same  kind  of  matter  which  forms  the  granules  above  described, 
deposited  in  the  cellular  tissue  of  the  lungs  in  irregular  masses, 
sometimes  one,  two,  or  even  three  inches  in  cubic  dimensions, 
without  definite  boundaries,  or  limited  only  by  the  extent  of  the 
lobules.  It  is  hard,  homogeneous,  translucent,  and  of  a  grayish 


294  THORACIC    DISEASES. 

color,  sometimes  darkened  by  the  black  matter  of  the  lungs,  por- 
tions of  which  become  enveloped  in  the  masses  as  they  are 
formed.  In  some  instances,  no  traces  of  pulmonary  tissue  can  be 
detected  in  the  masses ;  in  others,  they  present  remains  of  blood- 
vessels, bronchial  tubes,  and  cellular  membrane  ;  and  occasionally 
they  are  partially  penetrated  by  the  air  in  respiration. 

"  3.  Gelatinous  Infiltration. — Under  this  name  Laennec  de- 
scribed a  colorless  or  rose-colored  substance,  more  transparent  than 
the  gray  matter  noticed  in  the  last  paragraph,  and  of  a  jelly-like 
consistence,  which  he  had  observed  to  be  deposited  in  small  quan- 
tities in  the  tissue  of  the  lungs,  in  the  intervals  of  the  tubercular 
granules,  and  which  he  believed  to  be  gradually  converted  into 
proper  tuberculous  matter.  Louis  states,  that  he  has  met  with 
this  species  of  infiltration,  but  has  not  noticed  in  it  the  yellow  tu- 
berculous points  spoken  of  as  not  uncommon  by  Laennec.  Dr. 
Morton  in  his  Illustrations  of  Pulmonary  Consumption,  gives  two 
cases  in  which  the  tuberculous  transformation  appeared  to  have 
commenced  in  this  gelatinous  matter. 

"4.  Crude  Tubercle  and  ^fellow  Tuberculous  Infiltration. — 
The  gray  translucent  matter  constituting  the  first  two  deposits 
above  noticed,  appears  to  undergo  a  gradual  conversion  into  what 
has  usually  been  considered  the  proper  tuberculous  substance.  In 
the  miliary  granulations,  the  transformation  commences  in  a  small 
yellowish- white  spot,  which  most  commonly  appears  at  or  near 
the  centre,  and  gradually  enlarges  until  the  whole  granule  assumes 
that  character.  In  this  altered  state,  the  little  bodies  are  now 
generally  denominated  crude  tubercles.  In  the  aggregated  gran- 
ules, the  change  commences  at  several  points,  each  probably  an- 
swering to  a  distinct  granule  ;  and  considerable  masses  of  yellow 
opaque  matter  result  from  the  extension  and  ultimate  coalescence 
of  these  central  spots.  The  same  transformation  takes  place  in 
the  infiltrated  translucent  matter,  beginning  in  like  manner  with 
isolated  opaque  spots,  and  spreading  until  it  involves  the  whole 
deposit,  which,  when  thus  altered,  receives  the  name  appropriated 
to  it  by  Laennec  of  yellow  tuberculous  infiltration.  This  may 
be  distinguished  from  the  crude  tubercle  by  an  irregular  and  an- 
gular, instead  of  roundish  form,  and  by  a  less  definite  line  of 
division  between  it  and  the  pulmonary  tissue.  There  is  no  doubt, 


PHTHISIS.  295 

that  both  the  crude  tubercle  and  yellow  infiltration  are  often  orig- 
inally deposited  in  this  state,  without  the  preliminary  formation  of 
the  translucent  matter. 

"Progress  of  Tubercles. — The  yellow  tubercle,  whether  orig- 
inal, or  the  result  of  a  transformation  of  the  gray  granulation, 
gradually  increases  by  new  accretions.  As  observed  upon  dissec- 
tion, it  varies  in  size  from  the  magnitude  of  a  pea  to  that  of  a 
hen's  egg,  is  irregularly  roundish,  and  consists  of  a  yellowish- 
white,  opaque,  friable  substance  which  easily  breaks  up  between 
the  fingers.  In  relation  to  its  chemical  composition,  microscopic 
characters,  and  peculiar  constitution,  the  reader  is  referred  to 
Dr.  Wood's  article  on  tuberculosis."  [Wood's  Practice  of  Med- 
icine.] 

The  next  change  in  tubercle  is  that  of  softening.     This,  by 
many  authors,  is  said  to  begin  in  the  centre,  and  to  gradually  ad- 
vance to  the  circumference.     Concerning  the  truth  of  this,  there 
is  however,  some  doubt.     The  reasons  as  given  by  Mr.  Carswell 
upon  which  such  a  doubt  is   based,  are  the  following : — Tuber- 
cular matter   according  to  his  theory  is   contained  in   the  air-cells 
and  bronchi.      If,  therefore,  this  morbid  product  is  confined  to  the 
surface  of  either,  or  has  accumulated  to  such  a  degree,  ns  to  leave 
only  a  limited   central  portion  of  their   cavities    unoccupied,  it   is 
obvious  that  when  they  are  divided  transversely,  the  following  ap- 
pearances will  be  observed  : — 1st.  A  bronchial  tube  will  resemble 
a  tubercle  having  a  central  depression  or  soft  central  point  in  con- 
sequence of  the   centre  of  the  bronchus  not  being,  or   never  hav- 
ing been  occupied  by  the  tuberculous  matter,  and  of  its  contain- 
ing at  the   same  time  a  small  quantity  of  mucus   or  other  secret- 
ed fluids  : — 2nd.   The   air  cells   will  exhibit  a   number  of  similar 
appearances,  or  rings  of  tuberculous  matter  joined  together,  and 
containing  in  their  centres  a  quantity  of  the   same  kind  of  fluids. 
When  the  bronchi  or  air-cells  are   completely  filled  with  tubercu- 
lous matter,  no  such   appearances  as  those  we  have  just  described 
are  observed,  and  hence  the  reason  why  tubercle,  in  such  circum- 
stances, has  been  said  to  be  still  in  the  state  of  crudity,  or  in  that 
state  which  is  believed  to  precede  the  softening  process. 

The   term   encysted   has  been  applied  to   tubercles.     But  this 
term  is  liable  to   deceive.     The   walls  of  the   cyst   are   nothing 


$96  THORACIC    DISEASES. 

more  than  the  parietes  of  the  vesicles  distended  with  tuberculous 
matter.  A  biliary  duct  distended  by  a  morbid  deposit,  has,  like- 
wise, been  called  through  the  same  mistake,  an  encysted  tubercle. 
As  the  softening  process  advances,  the  whole  tubercle  becomes 
converted  into  a  "  soft,  pultaceous,  yellowish  mass,''  in  appearance 
resembling  pus.  The  infiltrated  mass,  likewise,  undergoes  a  sim- 
ilar change.  Sometimes  the  entire  tuberculous  deposit  seems 
throughout  its  whole  mass,  to  become  suddenly  softened  ;  and,  in 
this  manner,  large  portions  of  the  lung  are  quickly  destroyed. 

The  pressure  of  the  growing  tubercles  upon -the  circumjacent 
lung  at  first,  makes  it  less  vascular.  But  reaction  at  length  takes 
place,  and  inflammation  succeeds ;  and  congestion,  ulceratiou  and 
suppuration  follow.  In  some  cases  the  tubercular  disease  passes 
through  its  various  stages  without  giving  rise  to  marked  inflam- 
mation. In  the  majority  of  cases,  however,  the  bronchi,  air-cells, 
and  cellular  tissue,  are  more  or  less  affected  by  the  inflammatory 
process.  The  succeeding  ulceratiori  gives  rise  to  the  formation  of 
cavities.  Frequently  one  large  vomica  is  made  up  of  several 
smaller  ones,  which  in  the  parietes  of  the  large  cavity,  make  ex- 
cavations of  irregular  shape,  now  winding,  and  now  crossed  by 
bands  of  tissue.  The  size  of  the  cavity  varies  from  that  of  a  pea 
to  that  of  an  orange.  Its  contents  consist  of  a  mixture  of  pus 
and  bloody  matter,  and  portions  of  pulmonary  tissue.  Some- 
times they  are  inodorous,  sometimes  fetid.  In  children  the  vom- 
icse  are  less  common,  than  in  adults.  As  the  disease  advances,  a 
false  membrane  begins  to  form  around  the  decaying  tubercle,  at 
first  thin  and  delicate,  but  subsequently  becoming  more  dense  and 
fibrous.  In  some  cases  it  is  composed  of  layers,  resembling  fibro- 
cartilage,  in  others  remaining  delicate,  and  in  appearance  resemb- 
ling mucous  membrane.  Large  abscesses  are  sometimes  seen,  be- 
tween which  and  the  bronchi  there  is  no  communication. 

Cicatrization  of  Tuberculous  Cavities. — That  this  is  not  a  very 
rare  occurrence  Laennec  proved  in  his  early  researches  into  the 
termination  of  tuberculous  disease.  Indeed,  from  this  we  learn 
that  phthisis  sometimes  terminates  favorably.  This  happers 
when  the  deposit  is  limited  in  extent.  But  sometimes,  at  the  apex 
of  the  lung  we  find  an  old  adhesion,  sometimes  a  crust  of  fibro- 
cartilaginous  deposit,  or  even  a  fibrous  band  passing  from  the  lung 


PHTHISIS.  297 

to  the  ribs.  Adjacent  to  this  pathological  change,  the  lung  is 
puckered,  and  drawn  inward.  To  the  touch  it  feels  firm  and  con- 
solidated ;  to  the  eye  it  appears  dark,  from  an  abundant  deposit,  of 
black  pigment.  On  making  an  incision  we  find  a  cavity,  lined 
by  "  gray  fibrous  membrane,  semi-transparent ;  or  thick,  whitish 
and  fibro-cartilaginous  ;  or  soft  and  pliable,  like  the  mucous  mem- 
brane." 

This  cavity  is  usually  about  the  size  of  a  pea  or  a  plum,  and 
not  unfrequently  opens  into  the  bronchi.  It  contains  a  transpar- 
ent viscid  fluid,  and  in  some 'cases  tuberculous  matter  partly  trans- 
formed into  cretaceous  substance.  Around  the  cavities,  the  lung 
is  more  or  less  indurated  by  chronic  inflammation.  In  some  cases 
they  are  filled  with  fibro-cartilaginous  formations,  which  almost 
obliterate  the  vomicas.  At  the  summit  of  the  lungs,  other  evi- 
dence of  the  previous  existence  of  a  curative  process,  sometimes 
exists.  There  are  adhesions,  and  indurations  similar  to  those  in 
other  parts  of  the  pulmonary  parenchyma,  but  in  the  vomicae 
there  are  also  small  masses  of  a  chalk-like  appearance,  of  stony 
hardness,  feeling  gritty  or  earthy  to  the  touch.  These  small  bod- 
ies have  been  called  ossifications,  but  they  are  effects  of  progres- 
sive changes  in  tubercles.  Galen  and  Paul  of  Egina,  Bonnet  and 
Schenck  saw  them  in  great  numbers ;  and  Bayle  considered  them 
as  one  of  his  six  forms  of  phthisis.  By  Laennec  these  concre- 
tions are  divided  into  cartilaginous,  osseous, petrous  and  cretaceous. 
These  are  seldom  numerous,  and  are  most  often  found  at  the  sum- 
mit of  the  lungs.  Their  size  and  number  are  so  small  that  we 
may  reasonably  conclude  that  they  must  have  originated  from  a 
limited  deposition  of  tubercle.  Every  thing  connected  with  their 
history,  would  seem  to  prove  that  they  are  the  effects  of  that  nat- 
ural process,  which  nature  institutes  to  remove  the  disease.  Laen- 
nec well  remarks  "  that  they  show  in  a  train  of  diseased  action 
that  tubercles  are  cured."  Sometimes  they  remain  in  a  latent 
state,  not  exciting  irritation  or  inflammation. 

But  how  arc  these  concretions  formed  ?  To  this  question  Dr. 
Swett  replies,  "  they  are  effected  by  the  deposit  of  mineral  matter, 
the  chloride  of  sodium,  the  sulphate  of  soda  united  with  a  little 
phosphate  and  carbonate  of  lime,  and  sometimes  with  cholesterine 
in  the  place  of  the  proper  matter  of  tubercle.  But  every  stone- 
38 


298  THORACIC    DISEASES. 

like  concretion  that  is  formed  in  the  lungs  is  not  necessarily  a  con- 
verted tubercle.  This  condition  may  result  also  from  a  deposit  of 
lymph  which  passes  gradually  into  a  cartilage-like  or  bone-like 
condition,  or  it  may  be  owing,  as  some  think,  to  a  partial  ossifica- 
tion and  obliteration  of  the  smaller  bronchial  tubes."  Andral's 
opinion  was  that  they  are  formed  by  the  solidification  of  mucus 
in  the  minute  branches  of  the  bronchi. 

The  seat  of  tubercles  has  been  a  subject  of  much  diversity  of 
opinion.  Some  have  located  them  in  the  glands.  Of  this,  Dr. 
Wood  remarks  that  there  is  no  proof.  Some  contend  that  they 
are  the  result  of  effusion  into  the  air-cells ;  others  that  they  have 
their  seat  in  the  radicles  of  the  veins,  and  still  others  that  their 
location  is  in  the  bronchial  tubes  and  inter-vesicular  tissue.  These 
diverse  opinions  should  lead  to  the  conclusion  that  tuberculous 
deposition  takes  place  in  many,  if  not  in  all  of  the  tissues  of  the 
lungs. 

More  often  tubercular  cavities  are  situated  towards  the  posterior 
part  of  the  lung,  than  the  anterior.  One  lung  according  to  Louis, 
is  more  liable  to  this  deposition  than  the  other.  "  Modern  observ- 
ers have  collected  numerical  statements  showing  that  this  really 
is  so.  Why  it  should  be  so,  I  know  not.  Thus  Louis,  whose 
volume  is  the  result  of  immense  labor  in  observing,  and  is  full  of 
the  most  instructive  matter,  had  .met  with  seven  cases  in  which 
tubercles  were  confined  to  a  single  lung  ;  in  two  of  the  seven 
cases  it  was  the  right  lung  that  was"  thus  exclusively  affected,  in 
jive  it  was  the  left.  Of  38  instances  in  which  the  upper  lobe  was 
totally  disorganized  by  the  disease  on  one  side,  28  were  of  the 
left,  and  only  10  of  the  right.  Eight  times  he  had  known  the 
pleura  perforated  by  the  extension  of  tubercular  disease  ;  and 
seven  times  out  of  the  eight  the  perforation  happened  on  the  left 
side  of  the  chest.  So  also  Reynard  met  with  27  cases  of  pneu- 
mothorax  on  the  left  side,  to  13  on  the  right.  No  less  curious  is 
it  that  here  also  the  facts  ascertained  with  respect  to  pneumonia, 
are  just  the  contrary  of  those  which  belong  to  phthisis.  I  men- 
tioned, in  a  former  lecture,  Andral's  conclusion,  derived  from  the 
observation  and  collection  of  210  examples,  that  pneumonia  is 
more  than  twice  as  common  on  the  right  side,  as  on  the  left.  M. 
Lombard,  of  Geneva,  found  the  ratio  somewhat  less  than  this,  but 


PHTHISIS.  299 

still  great.  Of  868  instances  of  pneumonia,  413  occurred  on  the 
right  side  alone,  260  on  the  left  alone,  and  195  on  both  sides  at 
once.  That  is,  there  were  three  on  the  right  side  alone,  for  every 
two  on  the  left  alone."  [Watson's  Lectures.] 

In  very  many  cases,  however,  tubercles  are  found  in  both  lungs, 
in  each,  the  severity  of  the  disease  being  about  equal. 

Tubercles  vary  greatly  in  number  and  in  the  form  of  their  dep- 
osition. Sometimes  they  are  nearly  isolated,  at  other  times,  they 
are  found  in  successive  crops,  and  in  every  stage  of  development. 
Indeed  post-mortem  examinations,  often  reveal  several  cavities, 
miliary,  crude  tubercles,  and  tuberculous  infrltration  existing  to- 
gether in  the  same  lung — the  marked  effects  of  successive  crops 
of  tuberculous  deposition. 

Bayle  described  certain  semi-transparent  oval,  flattened  bodies, 
about  equal  in  size,  and  scattered  through  the  lungs,  to  which  he 
gave  the  name  of  accidental  cartilages.  Their  appearance  is 
somewhat  similar  to  rniliary  tubercles ;  from  which  they  may  be 
distinguished  by  their  more  uniform  size  and  their  more  equal 
distribution. 

Adhesions  are  almost  always  present  in  phthisis.  In.  112  cases 
examined  by  Louis,  there  was  only  one  in  which  no  adhesion 
was  found.  To  some  extent  their  location  corresponds  to  that  of 
tubercles.  In  rare  cases,  the  entire  surface  of  the  lung  is  bound 
down  to  the  costal  pleura,  and  to  that  of  the  diaphragm.  These 
have  the  effect  to  prevent  pneumothorax.  The  trachea  and  bron- 
chial tubes  often  arc  the  seat  of  extensive  lesion.  Those  are 
most  often  affected  which  form  a  way  of  exit  to  vomica3.  Their 
posterior,  more  often  than  their  anterior  internal  surfaces  are  af- 
fected. The  larynx  and  epiglottis  are  sometimes  the  location  of 
tuberculous  disease.  Among  other  lesions  attending  phthisis,  are 
partial  emphysema  of  the  lung,  dilatation  of  the  bronchi,  and  en- 
largement of  the  bronchial  glands.  This  latter  effect  is  most  com- 
mon in  children. 

Appearances  in  other  parts  of  the  body. — The  origin  of  tuber- 
cles being  in  the  blood,  their  distribution  throughout  the  entire 
system,  is  a  necessary  result.  But  according  to  Louis,  this  gener- 
al law  is  established,  that  when  tuberculous  deposit  exists  in  other 
organs,  it  always  exists  in  the  lungs.  The  converse  of  this,  is 


300  THORACIC    DISEASES. 

far  from  being  true ;  and  the  law  itself,  is  occasionally  subject  to 
exceptions,  the  occurrence  of  which  is  most  frequent  in  children. 
Without  the  lungs  the  tuberculous  depositions  most  often  are  com- 
posed of  the  yellow,  opaque  tubercle.  Gray  granulations  or  mil- 
iary  tubercles,  have  also  been  observed  in  various  parts  of  the 
body.  From  some  form  of  tubercle,  scarcely  an  organ  of  the 
body  is  wholly  exempt.  They  are  found  in  the  liver,  intestines, 
mesentery,  prostrate  gland,  testicles,  heart,  bladder,  uterus,  spleen 
and  kidneys,  and  in  the  membranes  and  substance  of  the  brain. 
It  was  the  conclusion  of  Louis  that,  of  all  the  cases  of  tubercles 
occurring  in  persons  over  the  age  of  fifteen  years,  one  third  had 
them  in  the  small  intestines,  one  fourth  in  the  mesenteric  glands, 
one  ninth  in  the  large  intestines,  one  tenth  in  the  cervical  glands, 
one  twelfth  in  the  lumbar  glands,  and  one  fourteenth  in  the  spleen. 
The  stomach  becomes  larger  than  natural,  more  thin,  and  is 
subject  to  chronic  inflammation  of  its  mucous  surface.  The 
glands  of  Peyer, — those  near  the  cascum, — become  the  seat  of 
tubercles.  The  mucous  glands  of  the  small  intestines  sometimes 
ulcerate,  causing  perforation  and  the  admission  of  the  faecal  secre- 
tions into  the  cavity  of  the  peritoneum.  A  similar  diseased  state 
of  the  large  intestines  sometimes  occurs.  The  mesenteric  glands 
are  very  much  enlarged.  In  the  brain,  tuberculous  deposition 
gives  rise  to  hydrocephalus. 

SECTION  II. 
GENERAL  SYMPTOMS  AND  COURSE  OF  PHTHISIS. 

Since  the  discovery  of  the  physical  signs  by  Laennec,  the  ten- 
dency of  some  minds  has  been  to  disregard  the  general  symptoms 
in  the  formation  of  a  diagnosis.  Among  such,  an  unnecessary 
delay  is  often  caused  in  the  application  of  remedial  agents;  for 
the  general  symptoms  very  frequently  are  the  first  indications  of 
approaching  disease.  A  diagnosis  should  not  then  be  wholly  de- 
pendent upon  the  physical  signs  in  the  first  stage:  for  these  are 
seldom  manifest  until  the  disease  has  so  far  progressed  as  to  make 
a  prognosis  unfavorable. 

Certain  general  symptoms  are  grouped  together,  and  said  to  be 


PHTHISIS.  301 

indicative  of  the  scrofulous  diathesis  or  tuberculous  cachexia. 
What  this  condition  of  the  system  is,  or  what  its  influence,  in  the 
development  of  phthisis,  it  may  be  difficult  to  accurately  ascer- 
tain, and  yet  the  description  of  some  of  its  more  important  symp- 
toms may  be  of  utility  in  detecting  that  first  pathological  change 
in  which  phthisis  begins. 

Among  the  more  important  symptoms,  are  a  pale,  pasty,  appear- 
ance of  the  countenance,  large  upper  lip  and  alee  nasi.  In  persons 
of  a  dark  complexion,  the  skin  is  sallow,  in  those  of  fair  com- 
plexion, it  is  unnaturally  white,  resembling  blanched  wax  rather 
than  the  healthy  countenance.  The  veins  are  large  and  conspic- 
uous, the  pupils  of  the  eyes  are  large,  eyelashes  long,  with  a  fair, 
florid  complexion.  In  persons  of  a  bilious  temperament,  the  skin 
is  coarse,  its  color  dingy.  The  form  of  the  body  is  often  desti- 
tute of  symmetry.  The  head  is  large,  trunk  small,  abdomen, 
tumid,  limbs  unshapely ;  the  growth  of  the  body  is  irregular,  the 
functions  of  nutrition  are  feeble,  and  deranged.  The  intellect  is 
often  very  active,  there  is  great  sensibility  to  impressions  and 
acuteness  of  mind. 

The  bowels  are  usually  more  or  less  irregular,  more  often  slow 
in  their  action  than  the  reverse;  the  urine  turbid,  the  skin  soft, 
dry  and  flaccid,  or  dry  and  harsh.  The  muscles  are  soft  and  desti- 
tute of  much  firmness  of  texture  and  the  circulation  is  feeble.  There 
is  a  great  tendency  to  catarrhal  affections,  which  are  prone  to  con- 
tinue a  long  time  and  to  cause  a  discharge  of  thick  yellow  mucus. 

In  children,  the  eyelids  and  ears  are  often  subject  to  chronic  in- 
flammation. The  fauces  and  tonsil  glands  are  seldom  free  from 
chronic  disease.  The  lymphatic  glands  enlarge  on  slight  expos- 
ure. The  catamenia  in  females  are  tardy  in  their  appearance,  ir- 
regular in  their  return. 

Stages. — For  convenience  in  description,  phthisis  has  been  di- 
vided into  three  stages.  Between  these  no  line  of  demarkation  is 
accurately  drawn.  The  first  stage  begins  with  the  onset  of  the 
disease,  and  ends  when  softening  of  tubercles,  has  commenced. 

General  Symptoms. — The  pulse  is  accelerated,  especially  after 
eating,  towards  evening,  or  by  slight  exercise.  A  burning  sensa- 
tion is  felt  in  the  palms  of  the  hands  and  soles  of  the  feet.  To- 
wards evening  a  slight  chilliness  comes  on,  towards  morning  per- 


302 


THORACIC    DISEASES. 


spiration  supervenes.  The  febrile  paroxysm  is  sometimes  very 
slight,  scarcely  attracting  notice,  sometimes  severe,  causing  un- 
pleasant sensations,  and  exciting  alarm.  Sleep  ceases  to  refresh, 
food  to  give  strength  and  vigor.  The  aspect  of  the  patient  chang- 
es ;  the  countenance  is  pale,  expressive  of  languor  or  red  with  the 
hectic  flush.  The  skin  is  less  elastic,  the  muscles  less  firm,  men- 
struation is  tardy  or  entirely  wanting  ;  emaciation  becomes  evi- 
dent. If  these  symptoms  have  appeared  in  the  spring  time,  by 
the  use  of  proper  remedies,  and  regimen,  they  are  almost  entirely 
removed,  until  the  returning  autumn  and  winter,  bring  them  on 
with  increasing  severity.  Occasionally  they  seem  to  arise  from 
bronchitis,  pleuritis,  pneumonitis  or  some  febrile  disease.  When 
they  succeed  to  measles  or  scarlet  fever,  they  frequently  progress 
with  unwonted  rapidity. 

The  rational  symptoms,  are  subject  to  much  variation.  In  most 
cases,  however,  a  short  dry  cough  is  one  of  the  first  symptoms 
that  excites  alarm.  Often  very  slight,  a  mere  hacking  in  the 
morning,  it  steadily  increases,  and  at  length,  is  accompanied  with 
an  expectoration  of  frothy,  transparent  mucus,  and  afterwards  of 
yellow,  opaque  matter.  Slight  dyspnoea  occurs  when  the  patient 
exercises.  About  the  sides  and  shoulders  there  are  fugitive  pains. 
Slight  hemorrhage  from  the  lungs  occurs  ;  at  times,  it  may  be 
somewhat  copious,  but  often  small  in  quantity.  As  the  disease 
progresses,  the  cough  increases,  preventing  sleep,  and  sometimes 
occurring  in  paroxysms.  The  expectoration  is  correspondingly 
increased,  becoming  thicker,  more  yellowish,  or  greenish,  and  pur- 
ulent. Th'e  other  symptoms  usually  advance  with  equal  pace. 
Sometimes,  the  disease  is  very  insidious  in  its  approach.  Sud- 
denly without  any  premonition,  a  violent  attack  of  hemoptysis 
occurs,  immediately  succeeded  by  all  the  appearances  of  confirmed 
phthisis.  These  rational  symptoms  are  intimately  connected  with 
the  tubercular  deposition.  The  tubercles  are  in  a  state  of  crudity. 
Softening  has  not  yet  commenced.  They  are  in  the  form  of 
small,  roundish  homogeneous  bodies,  collected  in  clusters,  or  more 
widely  disseminated  through  the  lungs  in  the  form  of  miliary  tu- 
bercles. Sometimes  they  are  more  or  less  firm,  of  a  grayish  color, 
or  translucent. 

When  closely  collected  together,  they  cause  a  consolidation  of 


PHTHISIS.  303 

the  pulmonary  tissue  which  gives  rise  to  obstruction  to  the  ingress 
and  egress  of  air  and  to  the  pulmonary  circulation.  Hence  the 
shortness  of  breath,  and  the  occasional  emphysema,  that  some- 
times occur.  Other  effects  resulting  from  a  consolidation  of  por- 
tions of  the  lung  by  the  deposition  of  tubercles,  are  sanguineous 
congestion,  oedema,  gangrene,  haemoptysis  and  effusions  into  the 
pleura.  Hccmoptysis  in  the  early  stage  of  consumption  is  gener- 
ally from  this  cause,  and  it  is  a  serious  symptom,  not  only  because 
it  may  endanger  life  by  the  loss  of  blood,  or  by  suffocation,  but 
because  it  is  accompanied  by  hemorrhagic  consolidation,  and  rup- 
ture of  pulmonary  tissue. 

Physical  Signs. — In  the  nascent  state  of  phthisis,  we  cannot 
derive  positive   information  from  physical   exploration.     In  order 
to  produce  abnormal  sounds  on  percussion  and  auscultation,  the 
deposit  of  tubercles  must  be  considerable,   or  there   must  be  in 
some  one  part  of  the  lungs, — be  it  ever  so  limited, — a  deposit  suf- 
ficiently great  to  interfere  with  the  pulmonary  functions.     If  the 
tubercles  are  small  and  scattered,  the  physical  signs  will  not  be  so 
sure  to  detect   the  morbid  change.     If  on  the  contrary  they   are 
large  and   clustered  together,  abnormal   sounds  will  be  the   more 
readily   developed.     So  that  it  is  evident  that  the  physical  signs 
cannot  determine  the  absolute  amount  of  tuberculous  deposition  j 
since  the  arrangement  of  tubercles,  as  well  as  their  number,  has  a 
modifying  influence.     Shall  we  therefore,  conclude  that  the  phys- 
ical signs  are  of  no  practical  utility?     As  well  might  we   deny 
the  usefulness  of  the  telescope  because  it  does  not  reveal  all   the 
minute  phenomena  of  the  heavens.     Because  no  one  of  the  phys- 
ical  signs  is  absolutely   pathognomonic  we  should  not  .conclude 
that  their  evidence,  added  to  that  afforded    by  the  general    symp- 
toms, is   not  of  great  value.      These    signs  found   at   the  points 
most  subject  to  tubercular  disease,  the  comparative   rarity  of  any 
other  lesions  capable  of  producing  the  same  physical  phenomena, 
enable  us  to  arrive  at  a  degree  of  probability  which  is  almost  equiv- 
alent to  certainty.      The  existence  of  the  two-fold  evidence  given 
by  the  general  symptoms,  and  the  physical  signs,  makes  the  diag- 
nosis far  more  sure  than  it  could  be  when  founded  only  on    one 
class  of  symptoms. 

Inspection  has  been  considered  of  some  value  in  the  diagnosis 


304  THORACIC    DISEASES. 

of  phthisis.  An  unusual  immobility  of  those  parts  of  the  thorax 
adjacent  to  the  location  of  tubercles,  is  mentioned  by  Andral,  and 
again  by  Dr.  Clark,  as  affording  valuable  evidence.  Laennec  never 
placed  much  dependence  upon  this  symptom,  nor  does  Louis  re- 
gard it  as  of  much  importance. 

Inspection  is  often  a  valuable  means  of  diagnosis.  Prominence 
of  the  clavicles,  contraction  of  the  intercostal  spaces,  a  flatness  of 
the  chest  in  front,  an  unequal  height  of  the  shoulders,  a  depres- 
sion of  the  ribs, — all  these  when  present  in  a  tuberculous  patient, 
indicate  the  presence  of  phthisis. 

Palpation  is  of  no  practical  utility.  In  the  last  stages,  a  mo- 
tion of  the  fluids  in  the  bronchi,  may  sometimes  be  heard ;  but  in 
the  early  stage,  nothing  definite  should  be  inferred  from  this  kind 
of  physical  exploration. 

Percussion  is  usually  somewhat  dull  in  the  early  stage,  under 
the  clavicles.  An  inequality  in  its  degree  on  opposite  sides  of  the 
chest,  and  at  points  equally  distant  from  the  median  line,  adds 
much  more  significance  to  this  physical  sign,  and  especially  if  the 
dullness  is  greater  on  the  left  side.  In  emphysema  and  pneumo- 
thorax,  a  similar  inequality  of  sound  may  exist.  In  these  instan- 
ces the  diseased  side  is  most  sonorous,  but  the  respiration  is  most 
feeble  where  the  resonance  is  greatest, — a  circumstance  which 
distinguishes  this  condition  from  phthisis.  An  emphysematous 
condition  of  the  lung  occurring  adjacent  to  the  location  of  solidi- 
fication from  tubercles,  may  cause  the  percussion  to  remain  nearly 
normal.  Were  this  coincidence  common,  it  would  certainly  dimin- 
ish the  value  of  percussion  in  diagnosis.  But  it  is  of  very  rare 
occurrence.  The  signs  derived  from  percussion,  should  be  sought 
about  the  clavicular  and  acromial  regions.  Obscurity  of  resonance 
being  detected  beneath  one 'or  both  clavicles,  or  at  any  point  of 
the  chest  near  to  the  apices  of  the  lungs,  what  conclusion  should 
be  formed  as  to  the  nature  of  the  disease  ?  To  this  question 
Chomel  repli'es : — "  Obscurity  of  sound  and  feeble  respiration  un- 
der one  of  the  clavicles,  give  strong  reason  to  suppose  the  exist- 
ence of  tubercles,  for  partial  effusions  take  place  in  the  immense 
majority  of  cases  at  the  inferior  and  posterior  parts  of  the  chest, 
and  it  is  almost  never  that  chronic  pneumonia  is  primitive  and 
without  the  presence  of  tubercles." 


PHTHISIS.  305 

In  the  early  stage,  the  slightest  difference  of  note  or  pitch  on 
opposite  sides  of  the  chest,  if  confined  to  the  clavicular  and  acro- 
mial  regions,  should  excite  suspicion.  Although  the  dullness  may 
be  confined  to  a  small  locality  over  the  top  of  the  shoulder,  and 
the  scaleni  muscles,  yet  if  it  be  clearly  perceptible  it  is  a  very  sure 
indication  of  the  existence  of  phthisis. 

Auscultation  in  the  first  stage,  reveals  a  feebleness  of  the  respi- 
ratory murmur  in  the  sub-clavicular  region.  This  occurs  where 
the  percussion  is  dull,  and  at  the  same  place  the  resonance  of  the 
voice  is  greater  than  normal.  While  in  one  part  of  the  lung  these 
signs  are  heard,  in  another,  the  respiration  is  blowing.  A  slight 
difference  of  sound  in  relative  situations  on  both  sides  does  not 
necessarily  indicate  phthisis.  The  anatomical  relations  of  the 
lungs  have  a  modifying  effect.  A  sound  in  the  right  lung  of  a 
phthisical  patient,  should  not  be  considered  as  indicative  of  tuber- 
cles, unless  it  is  decidedly  blowing.  But  if  the  respiration  is  more 
blowing  at  the  apex  of  the  left,  than  at  that  of  the  right  lung, 
there  can  be  but  little  doubt  that  tuberculous  disease  is  present. 
With  the  advance  of  the  disease,  the  respiration  becomes  some- 
what rough  or  even  bronchial,  with  a  prolongation  of  the  expira- 
tory sound  which  is  one  of  the  most  striking  characteristics  of  tu- 
berculous deposition.  Inspiration  is  at  times  somewhat  jerking. 
The  cardiac  pulsations  are  more  audible  than  usual.  Bronchial 
respiration  and  bronchophony  are  heard  out  of  their  natural  local- 
ity ;  thus  becoming  indications  of  pulmonary  lesion. 

The  hand  applied  to  the  sub-clavicular  region,  sometimes  is  able 
to  feel  an  increased  vibratory  motion  from  the  voice.  In  general 
these  signs  may  be  perceived  over  the  upper  portions  of  the  scapu- 
lae behind.  These  are  indicative  of  solidification  of  the  pulmon- 
ary tissues;  and,  when  this  condition  of  the  lung  is  present  be- 
neath the  sub-clavicular  region,  and,  when,  at  the  same  time,  there 
is  no  evidence  of  acute  pneumonitis,  the  probability  is  very  strong 
that  it  is  caused  by  tubercles. 

Second  stage. — The  second  stage  of  phthisis  may  be  consid- 
ered, as  beginning  with  the  softening  of  tubercles,  and  terminat- 
ing when  cavities  are  fully  formed,  and  all  the  physical  effects 
arising  from  them,  are  fully  developed.  In  other  words  it  is  the 
formative  stage  of  vornicse. 
39 


306  THORACIC    DISEASES. 

The  circumstance  which  has  been  considered,  as  marking  the 
passage  from  the  first  to  the  second  stage  of  phthisis,  is  a  remark- 
able change  in  expectoration. 

General  symptoms. — In  the  second  stage,  the  general  symp- 
toms for  the  most  part,  are  the  same  as  those  in  the  first,  differing 
mostly  in  degree,  and  not  in  kind.  That  there  is  an  arbitrary 
line  of  division  between  the  different  stages,  is  an  erroneous  idea. 
And  we  should,  therefore,  consider  the  various  changes  occurring 
in  the  progress  of  phthisis,  as  but  a  continuous  chain  of  abnor- 
mal phenomena, — a  chain  the  links  of  which  cannot,  and  should 
not  be  considered  as  separated  by  any  division  made  for  the  sake 
of  convenience  in  description. 

Of  the  general  symptoms  collectively,  I  remark  that  they  are 
more  severe.  The  evening  chills  are  more  constant  and  trouble- 
some, the  succeeding  heat  is  more  intense,  and  more  general,  the 
morning  sweats,  more  regular  and  copious.  Hectic  is  more  con- 
stant, and,  in  the  words  of  another,  "  hangs  out  upon  the  cheek 
the  red  flag  of  death ;"  the  pulse  is  more  frequent,  the  respiration 
quick  and  laborious  even  when  the  patient  is  at  rest.  Languor  and 
weakness  increase,  emaciation  is  rapid,  the  muscles  are  soft  and 
flabby,  and  the  patient  can  no  longer  endure  his  wonted  amount 
of  mental  or  physical  exertion.  Paleness  of  the  countenance  fre- 
quently remains  during  the  early  part  of  the  day.  Sometimes 
there  is  a  greater  tendency  to  chills  shown  by  an  increased  sensi- 
bility to  cold,  and  the  evening  exacerbation  brings  on  an  increased 
heat  of  the  palms  of  the  hands  and  soles  of  the  feet.  The  coun- 
tenance, under  the  influence  of  the  morbid  excitement,  is  for  a 
while  more  animated,  the  eye  brightens,  and  the  red  blush  of  hec- 
tic gives  to  the  features  new  beauty  and  loveliness.  When  speak- 
ing, the  lips  of  the  patient  slightly  quiver,  there  is  a  breathless- 
ness  which  interrupts  him  in  the  middle  of  a  sentence.  Sleep  is 
more  disturbed.  Not  unfrequently  the  mind,  even  in  this  stage  of 
the  disease,  is  buoyant  and  hopeful.  The  least  and  most  tempo- 
rary amendment  in  his  symptoms,  or  the  delusive  promises  and 
boasts  of  quacks,  inspire  him  with  the  joy  of  hope. 

Special  symptoms. — At  the  beginning  of  this  stage,  a  change  is 
observed  in  the  expectoration.  The  frothy,  colorless  sputa  which 
had  before  attended  the  cough,  now  contain  small  specks  of  opaque 


PHTHISIS.  307 

matter  of  a  pale  yellowish  color,  that  gradually  increase  forming 
patches,  surrounded  by  the  transparent  portion  in  which  they 
seem  to  float.  Streaks  or  specks  of  blood  are  also  seen  in  the 
expectoration.  With  this  change,  the  other  rational  symptoms  in- 
crease, the  cough  becomes  more  harrassing,  and  respiration  is  hur- 
ried. Haemoptysis  is  likewise  a  frequent  occurrence,  amounting 
sometimes  to  a  slight  streak  of  blood  in  the  expectoration,  at  other 
times,  to  a  considerable  quantity.  Darting  pains  are  frequent 
around  the  chest — the  result  of  pleuritic  inflammation  excited  by 
the  extension  of  the  tubercular  disease  to  the  pleura.  These  are, 
therefore,  usually  confined  to  that  part  of  the  lung  in  which  the 
tuberculous  disease  is  most  developed. 

The  Physical  signs  in  this  stage  are  more  marked.  As  the 
disease  advances,  the  tubercles  soften,  and  become  diluted  with  a 
morbid  secretion  from  the  pulmonary  tissues.  Particles  of  curdy 
or  cheesy  matter,  pass  from  their  locality  in  the  parenchyma  of 
the  lungs,  into  the  bronchial  tubes  and  are  expectorated.  The 
exit  of  this  matter  from  the  lungs,  gives  rise  to  the  formation  of 
little  vacuities,  called  caverns,  cavities,  vomicae,  or  excavations. 

A  careful  examination  of  the  chest,  at  this  time,  affords  posi- 
tive evidence  of  the  internal  mischief.  The  upper  parts  are  less 
freely  raised,  during  respiration  than  in  the  healthy  state ;  this 
phenomenon  frequently  being  more  evident  on  one  side  than  on 
the  other.  The  sub-clavicular  regions  on  both  sides,  give  a  dull 
sound  on  percussion.  To  the  mind,  the  ear,  or  stethoscope,  when, 
applied  to  those  portions  of  the  chest  situated  where  percussion  is 
dull,  reveals  a  slight  crackling  noise — the  crepitating  ronchus. 

After  vomicrc  are  formed,  the  cavernous  rale  or  the  gurgling  is 
heard,  when  the  cavity  is  partly  filled  with  liquid.  Resonance  of 
the  voice  and  cough,  and  at  length  pectoriloquy  follow. 

If  a  solidified  portion  of  lung,  enclosing  a  considerable  bron- 
chus, comes  near  to  the  surface  of  the  chest,  then  bronchial  breath- 
ing and  bronchophony  will  be  audible.  Percussion,  too,  will  give 
the  same  sound,  whether  the  lung  be  hepatized  or  blocked  up  by 
tubercular  matter.  This  condition  of  the  lungs  may  be  present 
in  one  part,  while  cavities  exist  in  another,  and  therefore,  different 
parts  of  the  chest  will  present  different  physical  signs.  I  have 
said  that  the  gurgling  sound  is  heard  in  case  the  vomica  contains 


TH011ACIC    DISEASES. 

liquid.  But  does  this  sound  necessarily  prove  in  all  cases,  the  ex- 
istence of  cavities  ?  Dr.  Watson  remarks  "  that  where  we  hear 
during  inspiration  or  coughing,  the  gurgling  rale, — called  by  Laen- 
nec  gargouillement — we  may  conclude,  that  there  exists  a  cavity. 
But  the  cavity  will  not  necessarily  be  a  vomica.  In  ninety-nine 
cases  out  of  a  hundred,  it  will  be  so ;  but  in  the  hundredth  case, 
perhaps  it  will  not."  Dilatation  of  the  bronchi,  sometimes  pro- 
duces a  considerable  globular  expansion.  In  case  these  cavities, 
formed  by  such  an  expansion  were  filled  with  a  liquid,  the  same 
sound  would  be  produced,  as  that  caused  by  the  tubercular 
vomica. 

Another  morbid  condition  of  the  lung  might  cause  the  same 
sound,  and  that  is  an  abscess  formed  by  inflammation.  When  the 
cavity  is  empty,  cavernous  respiration  would  be  heard.  The  size 
of  the  vomica  will  modify  the  nature  of  the  sound.  When  very 
small  it  may  be  and  often  is  "a  mere  click,  like  the  opening  and 
shutting  of  a  valve,  or  a  chirp,  or  a  creaking."  By  Dr.  Watson, 
all  these  modified  sounds,  are  called  by  the  same  name, — cavern- 
ous respiration. 

The  voice  is  generally  more  resonant  than  usual,  amounting,  in 
some  cases,  to  bronchophony.  Distinct  pectoriloquy  is  sometimes 
heard  in  one  or  more  points  of  the  clavicular  and  scapular  regions. 
These  indications  are  very  generally  more  evident  on  one  side, 
than  on  the  other,  and  hence  the  necessity  of  attending  to  this 
circumstance,  in  order  to  form  a  correct  diagnosis. 

The  length  of  time  during  which  a  person  may  continue  in 
this  state,  varies  in  a  great  degree.  In  some  cases,  a  few  weeks 
bring  him  to  the  brink  of  the  grave ;  in  others  many  months  and 
even  years  may  pass  away  without  any  apparent  increase  of  the 
symptoms. 

Third  stage.  The  third  stage  is  that  period  which,  commenc- 
ing when  cavities  are  already  formed,  and  all  their  attending  phe- 
nomena developed,  continues  until  the  termination  of  the  disease. 
This  has  been  called  the  colliqitative  stage,  from  the  copious  per- 
spiration, the  frequent  attacks  of  diarrhoea,  and  the  abundant  ex- 
pectoration with  which  it  is  attended.  The  feet  and  ankles 
become  cedematous,  the  vital  powers  gradually -decrease,  one  after 
another,  the  functions  of  life  fail;  the  body  by  afatilis  desce?isus, 
falls  to  the  earth  and  the  soul  rises  to  eternity. 


PHTHISIS.  309 

General  symptoms. — The  most  important  of  these  are  the  col- 
liquative  sweats,  the  diarrhoea,  extreme  emaciation,  anasarcous 
swelling  of  the  lower  limbs  and  high  febrile  excitement.  A  sure 
forerunner  of  approaching  dissolution  is  an  apthous  condition  of 
the  mouth.  This  usually  comes  on  during  the  last  weeks,  or  days 
of  existence. 

The  mental  faculties,  at  this  period  of  phthisis,  are  more  or  less 
deranged.  Reason  remains,  but  it  is  not  the  reason  of  health. 
Slight  delirium  sometimes  occurs  ;  the  patient  becomes  indifferent 
to  what  is  passing  around  Rim  and  to  his  own  state,  when  a  little 
while  before,  his  attention  was  aroused  by  every  unfavorable 
symptom. 

Special  symptoms. — The  expectoration  is  very  copious,  con- 
sisting of  a  heterogeneous  mass  of  mucus,  pus,  softened  and  oc- 
casionally solid  tubercle,  blood,  shreds  of  lymph,  rarely  portions  of 
pulmonary  tissue ;  sometimes  very  fetid.  The  cough  and  dys- 
pnoea increase.  The  shoulders  are  raised  and  brought  forward ; 
the  chest  is  narrow  and  flat.  During  respiration,  the  clavicular 
regions  are  less  movable  than  natural,  and  when  the  patient  at- 
tempts to  make  a  full  inspiration,  the  upper  part  of  the  thorax, 
instead  of  expanding  with  the  appearance  of  spontaneous  ease 
peculiar  to  the  healthy  state  of  the  lungs,  seems  to  be  forcibly 
dragged  up  at  each  respiratory  effort.  Perforation  is  most  fre- 
quent on  the  left  side.  Louis  found  it  on  that  side  in  seven 
cases  out  of  eight. 

There  is  an  accident  which  tends  to  ruffle  and  hasten  the 
course  even  of  the  quietest  forms  of  consumptive  disease  ;  this  is 
perforation  of  the  pleura,  and  the  consequent  pneumothorax  and 
acute  pleuritis  which  it  produces.  This  lesion  is  already  de- 
scribed. But  it  may  perhaps  be  well  to  point  out  the  sudden  dys- 
pnoea and  accession  of  sharp  pleuritic  pain,  occasioned  by  this 
morbid  accident.  This  occurs  more  frequently  in  males  than  in 
females.  Dr.  Williams  says,  "  that  he  never  has  seen  one  instance 
of  this  lesion  in  the  female,  while  he  has  seen  at  least,  twenty 
cases  in  the  male  sex.  The  place  where  it  usually  takes  place,  is 
the  lower  and  back  part  of  the  upper  lobe  of  the  lung,  opposite 
the  angle  of  the  third  or  fourth  rib,  that  is,  just  beneath  the  false 
membrane,  by  which  the  summit  of  the  lung  is  generally  ad- 
herent. 


310  THORACIC    DISEASES. 

Physical  signs. — The  physical  signs  in  the  third  stage,  are  sim- 
ilar to  those  of  the  second.  The  gurgling  rale,  the  increased  res- 
onance of  voice,  bronchophony,  and  pectoriloquy,  amphoric 
resonance  and  metallic  tinkling,  may  be  present  in  different  cases, 
and  at  different  times.  Some  of  these  signs  are  more  frequently 
heard  than  others.  The  metallic  tinkling  is  oftener  present  in  a 
large  than  in  a  small  cavity,  and  since  large  cavities  are  formed  in 
the  third  stage,  this  symptom  is  observed  only  when  the  disease 
is  far  advanced. 

But  what  are  we  to  infer  from  the  presence  of  metallic  tink- 
ling? A  cavity  must  exist,  and  liquid  be  present  in  it.  This 
condition  exists  in  pneumothorax.  How  can  we  distinguish 
the  metallic  tinkling  of  tubercular  cavities  from  that  arising  from 
liquids  in  the  pleural  sac  ?  1st. — By  the  location.  In  phthisis, 
the  largest  cavities  are  usually  at  the  apices  of  the  lungs.  In 
pneumothorax  the  cavity  is  towards  the  sides  of  the  chest,  and 
the  sound  is  heard  nearer  the  lower  part  of  the  thorax.  2nd. — 
By  the  absence  of  resonance.  When  the  pleural  sac  is  filled  with 
air,  the  sound  on  percussion  is  drum-like,  there  is  a  remarkable 
resonance.  But  over  tubercular  cavities,  percussion  is  dull,  and 
the  cause  giving  rise  to  that  dullness,  is  the  induration  of  the  layer 
of  lung  between  the  internal  surface  of  the  chest  and  the  cavity. 

The  amphoric  respiration,  too,  is  another  symptom  which  re- 
quires for  its  production  a  large  vomica,  with  hardened  and  smooth 
walls.  This  then,  on  account  of  the  nature  of  the  physical 
lesions,  must  be  most  frequent  in  this  stage.  Another  lesion  may 
give  rise  to  its  production.  It  is  a  perforation  of  the  pleura,  in 
which  case  the  amphoric  tone  is  extremely  well  marked,  or  the 
cavity  is  much  larger  than  one  formed  in  the  lungs,  and  its  walls 
are  large  and  elastic.  Its  different  location  and  distinctness,  to- 
gether with  the  other  symptoms  of  pneumothorax,  will  prevent 
a  wrong  diagnosis. 

Pectoriloquy  also  more  frequently  occurs  in  this  stage  of  the 
disease  than  in  any  other.  A  cavity  most  generally  gives  rise  to 
cavernous  respiration  in  breathing,  and  to  pectoriloquy  in  speak- 
ing. But  this  modification  of  the  healthy  sound  of  the  voice, 
should  not  be  considered  as  pathognomonic  of  the  existence  of  a 
cavity.  Solidification  of  the  lung  around  the  larger  ramifica- 


PHTHISIS.  311 

tions  of  the  bronchial  tubes,  may  give  rise  to  the  same  sound  of 
voice.  Of  the  relative  value  of  this  physical  sign,  Dr.  Stokes  ob- 
serves "that  alone  it  is  of  little  or  no  value.  Cavernous  respira- 
tion is  far  more  alarming.  Whenever  actual  pectoriloquy  from 
a  cavity  is  heard,  there  also  will  be  heard  cavernous  respiration. 
But  the  converse  of  this  is  not  necessarily  true.  There  may  be, 
and  there  often  is,  cavernous  respiration,  and  a  cavity,  and  yet 
no  pectoriloquy.  The  cavity  is  not  large  enough,  or  not  near 
enough  to  the  surface  of  the  chest,  or  not  of  such  a  kind  as  to 
reverberate  the  voice. 

"  Often  when  pectoriloquy  is  absent,  and  cavernous  respiration  is 
doubtful,  and  gurgling  even  cannot  be  heard — because  the  com- 
munication with  the  bronchi  is  not  free, — a  slight  splashing  sound 
will  occur,  when  the  patient  coughs ;  nay,  we  may  sometimes 
hear  it,  as  he  holds  his  breath,  with  every  beat  of  the  heart,  which 
causes  a  little  succussion  in  the  cavity;  but  its  contents  must  then 
be  thin."  [Watson.] 

When  these  sounds  are  present,  what  may  we  infer  ?  In  all 
cases  the  existence  of  a  cavity  is  indicated,  but  is  that  cavity  nec- 
essarily a  tuberculous  vomica  ?  Not  always.  A  cavity  formed 
by  pulmonary  abcess,  or  by  dilatation  of  the  bronchi,  may  give 
rise  to  the  same  physical  signs.  This  latter  condition  is  deceptive, 
but  it  seldom  occurs.  Dr.  Watson's  advice,  in  such  cases,  is 
appropriate.  "  When  the  sounds  are  not  well  marked  take  time 
before  you  pronounce  a  decided  opinion  respecting  them.  Strong 
bronchophony  conies  very  near  to  weak  pectoriloquy  :  bronchial 
respiration  may  closely  resemble  some  varieties  of  cavernous 
breathing:  large  crepitation  confined  to  a  small  spot,  may  similate 
gurgling.  It  is  better,  when  the  sounds  are  thus  equivocal,  and 
when  they  may  denote  conditions  so  very  different  in  their  nature 
and  tendency,  to  suspend  one's  judgment,  and  to  give  a  guarded 
opinion.  A  little  time  in  such  cases  will  clear  away  the  doubt." 

Particular  consideration  of  the  General  and  Rational  Symptoms. 

1.  Cough.  This  is  the  first  symptom  which  claims  our  atten- 
tion, being  in  most  cases  the  first  that  causes  alarm.  It  is  often 
slight  and  dry,  occurring  chiefly  in  the  morning  when  the  patient 
rises  from  his  bed,  or  during  the  day,  when  he  makes  any  uncom- 


THORACIC    DISEASES. 


mon  exertion.  In  this  state  it  is  scarcely  noticed.  To  the  patient 
it  appears  to  be  of  no  consequence.  But  its  increase  soon  be- 
comes evident.  In  some  cases  it  is  slight,  in  others,  severe.  In 
some  rare  instances  it  appears  only  a  few  days  before  death. 
Louis  gives  two  cases  of  this  ;  and  Portal  affirms  that  the  disease 
can  exist  without  the  slightest  cough.  In  general  it  is  most  com- 
mon at  night,  in  the  morning,  or  soon  after  meals. 

Catarrhal  cough  simulates  that  arising  from  tubercular  disease. 
In  general,  however,  it  may  be  easily  recognised.  The  catarrhal 
is  deep,  implicating  the  respiratory  muscles,  attended  with  sore- 
ness of  the  chest,  frontal  headache,  and  other  symptoms  of  ca- 
tarrh. It  is  soon  followed  by  expectoration,  at  first  colorless,  but 
soon  becoming  opaque,  then  assuming  a  yellowish  mucous  char- 
acter. From  this  time  the  cough  and  expectoration  begin  to  di- 
minish, and  under  ordinary  circumstances  soon  cease.  When  the 
catarrhal  disease  assumes  a  chronic  form,  more  difficulty  will  be 
found  in  learning  its  true  character.  In  case  the  patient  before 
the  catarrhal  symptoms  come  on,  has  been  subject  to  dyspoena  or 
haemoptysis,  tubercular  disease  should  be  strongly  suspected. 

Another  kind  of  cough  which  in  some  respects  simulates  that 
of  phthisis,  is  one  which  has  been  called  stomach  cough.  It  arises 
from  gastric  irritation.  In  general  it  is  louder  and  harder  than  the 
phthisical  cough,  and  frequently  comes  on  in  paroxysms  or  fits. 
The  sensation  which  excites  it  is  felt  deep  in  the  epigastric  region, 
and  the  irritated  state  of  the  stomach,  is  manifested  by  the  ordi- 
nary symptoms  of  gastric  derangement.  In  some  cases  this  is 
complicated  with  phthisical  cough,  in  which  case  means  should 
be  used  to  remove  the  gastric  derangement.  Symptomatic  cough 
may  arise  from  other  causes.  Disease  of  the  heart,  irritation  of 
the  liver  and  duodenum,  intestinal  worms,  and  disease  of  the 
uterus  often  give  rise  to  this  symptom.  The  cough  which  is 
present  in  chlorotic  females  may  generally  be  distinguished  from 
the  phthisical  cough  by  the  other  symptoms,  and  by  the  effect  of 
remedies  ;  those  means  which  relieve  the  former,  having  no  last- 
ing effect  upon  the  latter. 

Another  variety  of  cough  is  the  nervous.  This  is  produced  by 
excitement,  has  a  peculiarly  sharp,  barking  sound,  repeated  in 
quick  succession,  and  often  continues  an  hour  without  intermis- 
sion. It  is  frequently  the  effect  of  hysteria. 


PHTHISIS.  313 

Expectoration. — The  expectoration,  in  cases  of  suspected 
phthisis,  has  attracted  much  attention. 

It  was  thought  if  a  patient  spit  pus,  he  was  in  a  state  of  con- 
firmed consumption.  This  opinion,  however,  has  now  become 
obsolete,  and  few  physicians  now  base  a  diagnosis  upon  this  symp- 
tom alone.  Various  tests  have  been  discovered  in  order  to  detect 
its  presence  in  the  sputa.  Pus  globules  when  examined  through 
transmitted  light,  will  exhibit  prismatic  colors,  while  mucus  af- 
fords no  such  appearance.  The  liquor  potassce  liquifies' mucus, 
but  converts  pus  into  a  viscid,  stringy  mass.  The  sputa  come 
from  the  bronchi,  composed  of  mucus  and  yellow  or  greenish 
matter.  From  disease  of  the  trachea  and  bronchial  tubes,  a  puru- 
lent or  muco-purulent  discharge  often  takes  place.  And  hence 
the  presence  of  pus,  in  the  expectoration,  does  not  necessarily 
indicate  the  formation  of  tubercular  cavities,  or  even  the  softening 
of  tubercles.  Sometimes  the  sputa  appear  in  the  form  of  globu- 
lar flocculent  masses,  resembling  little  portions  of  wool. 

Dr.  James  Clark,  divides  the  sputa  into  two  varieties;  the  first, 
he  terms  the  striated  state  of  the  expectorated  mass,  with  a  mix- 
ture of  whitish  fragments  in  it;  the  second,  the  ash-colored  globu- 
lar masses  which  are  observed  in  the  more  advanced  stage  of  the 
disease. 

AY  hen  spit  into  a  vessel,  the  masses  composed  of  the  latter 
kind  mentioned  by  Dr.  Clark,  assume  a  flattened  round  appear- 
ance ;  they  are  adhesive,  and,  from  their  resemblance  to  a  piece 
of  money,  are  called  by  the  French  nummular. 

Each  sputum  in  general  preserves  a  distinct  form,  so  that  the 
number  of  expectorations  may  be  known  by  counting  the  number 
of  sputa. 

This  is  not  perfectly  pathognomonic,  but  is  nearly  so.  Louis 
saw  two  cases  in  which  this  kind  of  sputa  was  found  without 
any  connection  with  tuberculous  disease.  Chomel  had  one  case 
of  a  similar  character.  In  the  latter  stage  of  phthisis  it  is  some- 
times fetid,  and,  more  than  other  kinds  of  expectoration,  attracts 
flies. 

The  quantity  of  the  expectoration  varies  remarkably  in  differ- 
ent cases,  and  is  by  no  means  to  be  considered  commensurate  to 
the  extent  of  pulmonary  disease.  Sometimes  the  quantity  is  very 
40 


314  THORACIC    DISEASES. 

small,  although  after  death  large  excavations  are  found.  This 
may  arise  from  a  cavity  around  which  inflammation  has  so  com- 
pletely blocked  up  the  larger  vessels,  even  the  ramifications  of 
the  bronchi,  as  to  entirely  prevent  any  communication  of  the 
cavity  with  the  external  air.  A  case  of  such  a  character  recently 
came  under  my  observation.  In  the  right  lung  around  the  ram- 
ifications of  the  bronchi,  was  a  very  large  cavity,  filled  with 
muco-purulent  matter,  but  not  communicating  with  the  bronchi. 
No  expectoration,  at  least,  not  enough  to  call  the  attention  of  at- 
tendants, existed  during  the  progress  of  the  disease.  Dr.  Portal 
likewise  speaks  of  similar  instances. 

When  tubercles  are  crude  the  expectoration  comes  from  the 
bronchial  membrane.  Later  in  the  disease  it  comes  mostly  from 
the  bronchial  membrane,  but  partly  from  the  softened  tuberculous 
deposits.  The  surface  of  cavities  affords  an  additional  amount 
of  morbid  secretion.  The  quantity  generated  from  this  source  is 
sometimes  great,  but  often  it  is  extremely  small.  In  reviewing 
the  facts  already  stated  concerning  the  expectoration,  its  variations 
in  quantity,  in  appearance,  and  the  various  lesions  from  which  it 
originates,  we  may  safely  draw  the  conclusion,  that,  unless  com- 
bined with  other  symptoms,  it  cannot,  especially  in  the  early  stage 
of  phthisis,  be  considered  of  very  great  utility  in  forming  a  cor- 
rect diagnosis.  Later  in  the  disease,  in  conjunction  with  other 
symptoms,  it  has  value  in  enabling  us  to  ascertain  the  presence  of 
tubercles,  and  the  changes  which  occur  in  the  course  of  their  de- 
velopment. 

Dyspnoea. — This  symptom  varies  greatly  in  the  degree  of  its 
intensity  in  different  cases.  In  some  instances  it  occurs  early  in 
the  disease,  being  among  the  first  phenomena  which  attract  the 
patient's  attention ;  and  it  is  one  of  the  most  constant  and  remarka- 
ble symptoms  in  that  form  of  the  disease,  called  Febrile  Phthisis. 
More  frequently  it  is  not  troublesome  until  the  malady  is  far  ad- 
vanced, and  it  generally  becomes  very  distressing  in  the  last 
stages.  When  the  tuberculous  disease  makes  slow  progress,  the 
dyspncea  is  seldom  great ;  and,  in  persons  who,  from  their  quiet 
mode  of  living,  use  little  exercise,  it  is  scarcely  noticed,  even 
when  the  respiration  is  more  than  double  its  usual  frequency. 
In  such  cases  the  oppression  in  breathing  experienced  during  mo- 


PHTHISIS.  315 

tion,  is  very  often  attributed  to  debility.  Indeed,  it  is  by  no 
means  an  unfrequent  occurrence,  to  find  the  patient  unwilling  to 
admit  the  existence  of  such  dyspnoea  until  minutely  questioned 
on  the  subject. 

Although  we  shall  not  err  far  in  stating  that  the  degree  of  dys- 
pno2a,  or  hurried  respiration,  will  generally  be  found  proportionate 
to  the  rapid  progress  and  extent  of  the  tuberculous  disease  of  the 
lungs,  still  this  will  not  always  be  an  invariable  occurrence.  We 
are  not  yet  acquainted  with  all  the  causes  of  dyspnoea. 

Of  one  hundred  and  twenty-three  cases  reported  by  Louis, 
three  only  presented  examples  of  severe  dyspnoea,  and  a  careful 
examination  of  the  whole  contents  of  the  thorax  after  death,  de- 
tected nothing  to  explain  it.  A  degree  of  congestion  of  the  lungs 
commonly  exists  in  persons  of  a  tuberculous  constitution,  both 
before  and  after  the  formation  of  tubercles.  This  may  be  one 
cause  of  dyspnoea ;  and  hence  we  frequently  find  that  an  attack 
of  haemoptysis  relieves  the  dyspnoea  for  a  considerable  time.  On 
the  other  hand  it  not  unfrequently  happens  that  the  origin  of  the 
difficult  breathing  is  dated  from  an  attack  of  haemoptysis. 

Dyspnoea,  although  not  much  to  be  relied  upon  as  an  indication 
of  phthisis,  is  frequently  present,  and  should  always  be  a  subject 
of  inquiry.  It  is  chiefly  during  exertion  that  the  oppression  of 
breathing  is  experienced,  and  as  it  differs  little  from  that  which  in 
a  slight  degree  always  accompanies  such  exertion,  it  seldom 
attracts  attention.  It  occurs  most  frequently  when  sudden  and 
large  deposits  are  made,  or  when  there  is  tuberculous  infiltration. 
Congestion,  accumulations  of  mucus  in  the  bronchi,  pneurnothorax, 
extensive  pleuritic  adhesions,  so  binding  down  the  lungs  to  the 
parietes  of  the  thorax  as  to  prevent  their  normal  expansion,  are 
among  its  causes. 

Hcumoptysis. — This  is  the  most  important  rational  symptom 
which  occurs  in  phthisis.  In  other  diseases  and  conditions  of  the 
lungs  it  is  so  rare,  that  it  very  certainly  indicates  the  nature  of 
the  case.  Haemoptysis,  to  be  sure  may  be  produced  by  other 
causes ;  by  certain  forms  of  heart  disease,  by  cancer,  by  cirrhosis 
of  the  lungs,  and,  in  females,  by  vicarious  menstruation.  But 
these  latter  conditions  of  the  lungs  are  very  rare,  and,  therefore. 


316  THORACIC    DISEASES. 

haemoptysis  should  always  be  considered   a  strong  evidence  of 
the  existence  of  phthisis. 

Sometimes  it  occurs  very  early  in  the  disease,  often  it  is  the 
first  symptom.  The  quantity  of  blood  expectorated  varies  greatly 
in  different  cases.  When  it  exceeds  two  or  three  ounces  it  may 
be  called  a  free  hemorrhage.  When  less  than  this,  it  is  moderate. 
Profuse  hemorrhage  often  excites  gagging,  and  causes  some  of 
the  symptoms  of  hasmatemesis.  From  the  latter,  the  pulmonary 
hemorrhage  may  be  distinguished  by  waiting  until  it  has  nearly 
ceased,  when  the  coughing  will  indicate  that  the  blood  is  expec- 
torated. Not  unfrequently  the  blood  seems  to  come  from  the 
throat,  and  the  patient  very  often  is  inclined  to  refer  its  source  to 
that  locality ;  and  hence  the  physician  should  seldom  rely  upon 
his  statement  in  forming  his  diagnosis. 

The  hemorrhage  need  not  be  copious  in  order  to  be  indicative 
of  danger.  A  teaspoonful  of  blood,  mixed  with  a  little  mucus 
may  be  occasionally  expectorated  without  pain  or  effort.  But  lit- 
tle anxiety  is  excited  on  the  part  of  the  patient,  and  yet  when  re- 
peated it  is  quite  as  diagnostic  of  phthisis  as  a  more  copious  dis- 
charge. 

"Hemorrhage,  although  so  important  as  a  diagnostic  sign  of  tu- 
bercles, very  seldom  proves  fatal  by  its  immediate  effects;  neither 
.does  it  seem,  as  a  general  rule,  to  act  unfavorably  on  the  general 
progress  of  the  disease.  On  the  contrary,  statistical  tables  prove, 
that  those  phthisical  patients  who  experience  hemorrhage,  usually 
live  longer  than  those  who  do  not.  Oftentimes  the  flow  of  blood 
is  attended  with  a  feeling  of  decided  relief,  especially  if  it  as- 
sumes the  character  of  a  passive  hemorrhage.  Sometimes,  when 
it  assumes  an  active  character,  attended  with  febrile  excitement, 
and  induces  a  condition  of  lung  analogous  to  inflammation,  it 
may  produce  injurious  effects — an  active  period  in  the  progress  of 
the  disease  seeming  to  coincide  with  its  occurrence.  Thus  hem- 
orrhage is  not  always  to  be  regarded  in  the  same  light,  when  you 
look  at  individual  cases.  But  when  you  look  at  this  symptom  in 
the  mass  of  cases,  its  existence  must  be  regarded  as  exerting 
rather  a  beneficial  influence  than  otherwise.  There  are  many  per- 
sons, more  or  less  tuberculous,  who,  from  time  to  time,  expector- 
ate even  large  quantities  of  blood,  who  after  a  little  rest,  to  recruit 


PHTHISIS.  317 

the  exhausted  strength,  return  to  their  occupations,  and  live  on, 
year  after  year,  without  any  apparent  loss  of  health.  The  most 
protracted  case  of  phthisis  I  have  ever  known,  lasting  thirty-five 
years,  was  marked  by  occasional  returns  of,  sometimes,  very  copi- 
ous hemorrhage  during  this  long  period. 

"  I  have  stated  to  you  that  hemorrhage  from  the  lungs  did  not 
mark  the  stage  of  the  disease.  It  may  occur  early  or  late  in  its 
progress.  Formerly,  hemorrhages  were  attributed  to  two  causes, 
exhalation  from  a  free  surface,  as  the  mucous  membrane,  or  rup- 
ture of  a  blood-vessel.  But  microscopic  observations  have  estab- 
lished the  fact  that  there  can  be  no  such  thing  as  an  exhalation  of 
blood,  it  must  always  escape  from  a  ruptured  vessel.  It  may  lake 
place  from  numerous  capillary  vessels  ramifying  upon  the  surface 
of  the  bronchial  mucous  membrane,  and  this  is  probably  the  fact 
in  a  great  majority  of  the  cases  of  hemorrhage  connected  with 
tubercles — always  indeed,  when  it  occurs  at  an  early  stage  of  the 
disease.  Its  mechanism  is  simply  this : — The  tuberculous  deposit, 
by  pressing  upon  the  capillary  vessels  of  the  lungs,  obstructs  some 
of  them,  while  others  become  congested  in  consequence.  These 
congested  vessels,  when  seated  in  a  mucous  tissue,  become  rup- 
tured from  distension,  and  discharge  blood.  There  is  no  reason 
to  believe  that  the  capillaries  of  the  air-cells  or  of  the  common 
cellular  tissue  of  the  lungs  are  ruptured.  If  they  were  ruptured, 
you  should  find  pulmonary  apoplexy  in  fatal  cases.  But  this  is 
not  the  case.  Hemorrhage  may,  indeed,  occur  from  a  ruptured 
vessel  of  considerable  size,  from  ulceration.  This  can  only  hap- 
pen in  an  advanced  stage  of  the  disease ;  even  then  it  rarely  oc- 
curs from  this  cause.  When  it  does  occur,  it  is  usually  very  abun- 
dant and  difficult  to  control. 

"  When  patients  are  questioned  as  to  what  may  have  excited  the 
hemorrhage,  they  can  seldom  state  any  thing  which  seems  likely 
to  have  acted  as  an  exciting  cause.  In  a  large  proportion  of  cases 
it  occurs  quite  unexpectedly,  without  premonitory  symptoms. 
Sometimes  an  unusual  effort,  especially  of  the  chest,  seems  to  act 
as  an  exciting  cause  ;  and  in  women,  the  occurrence  of  the  men- 
strual period  may  induce  the  same  result. 

'•  Hemorrhage  would  undoubtedly  occur  more  frequently  and  co- 
piously than  it  does  in  the  progress  of  phthisis,  and  as  the  lungs 


318 


THORACIC    DISEASES. 


become  filled  with  the  tuberculous  deposit,  was  it  not  that  the 
quantity  of  blood  circulating  in  the  lungs  is  materially  diminished. 
The  blood  emaciates  like  the  other  parts  of  the  human  system. 
This  influence  is  felt  also  by  the  heart,  which  does  not  increase 
in  size  with  the  progress  of  the  pulmonary  obstruction,  as  you 
might  suppose,  but  it  rather  diminishes  in  size,  with  the  dimin- 
ished quantity  of  blood  in  the  circulation. 

"  I  am  not  afraid  that  I  have  dwelt  too  long  on  this  important 
symptom.  Its  frequency,  its  diagnostic  value,  its  influence  on  the 
prognosis,  the  great  alarm  it  usually  excites  in  the  patient,  and  in 
the  family,  make  it  worthy  of  the  most  careful  consideration." 
[Dr.  Swell's  Lectures.] 

Pain. — In  the  early  stage  of  phthisis,  this  is  seldom  very  severe,' 
and  in  some  cases  is  not  sufficiently  so  to  excite  attention.  Usu- 
ally there  are  flying  pains  through  the  shoulders  and  sides.  Their 
source  probably  is  the  external  intercostal  nerves.  In  many  re- 
spects ihey  may  resemble  rheumalic  pains.  But  their  history  and 
their  complication  with  other  symptoms,  will  easily  distinguish 
them.  Another  source  of  pain  is  inflammation  of  the  pleura,  aris- 
ing from  the  extension  of  the  pulmonary  disease  to  that  mem- 
brane. This  is  more  local  than  the  former  ;  and  from  the  ordin- 
ary locality  of  the  pathological  changes  by  which  it  is  produced, 
we  know,  that  it  should  be  confined  to  the  sub-clavicular  or  adja- 
cent regions.  In  general  its  locality  points  out  the  place  where 
the  tuberculous  disease  is  most  early  developed.  Combined  with 
other  symptoms,  it  is  of  some  value.  As  the  disease  advances, 
the  pain  increases.  When  confined  to  the  lower  part  of  the  chest, 
and  to  the  epigastric  region,  it  frequently  arises  from  inflammation 
of  the  pleura  of  the  diaphragm,  and,  therefore,  cannot  be  a  valu- 
able diagnostic  sign  of  phthisis.  The  pain  caused  by  catarrh,  dif- 
fers from  that  caused  by  phthisis.  That  arising  from  the  former 
disease  is  more  confined  to  the  sternal  region, — being  a  sensation 
of  soreness  rather  than  of  acute  pain,  extending  through  the  chest 
to  the  spine.  At  first,  the  decubitus  is  on  the  most  healthy  side. 
Late  in  the  disease,  it  is  often  the  reverse;  and  for  this  reason : — 
When  the  patient  lies  on  the  diseased  side,  the  matter  collects  in 
the  vomicae,  and  does  not  pass  into  the  bronchial  tubes  and  excite 


PHTHISIS.  319 

coughing.  Severe  pain,  and  dyspnoea,  coming  on  suddenly,  are 
indicative  of  that  important  lesion — the  perforation  of  the  pleura. 
Constitutional  symptoms. — The  state  of  the  pulse  is  a  symp- 
tom which  has  attracted  much  attention.  Its  real  value  in  diag- 
nosis has  been  overestimated.  An  opinion  is  too  prevalent  that 
the  lungs  are  safe  when  the  pulse  does  not  rise  above  its  normal 
standard.  Sometimes  it  remains  steady  nearly  up  to  the  period  of 
dissolution.  In  such  cases,  the  disease  progresses  slowly.  Dr. 
Watson  relates  a  case  in  which  the  pulse  never  rose  above  sixty- 
eight  beats  in  a  minute.  More  commonly,  however,  the  pulse  is 
habitually  above  ninety  ;  and  often  much  quicker.  Whenever  it 
is  so,  and  for  its  increase  in  frequency  no  other  cause  save  tuber- 
cular deposition  can  be  assigned,  it  is  a  suspicious  symptom. 

In  the  early  stage,  the  excitablity  of  the  pulse  is  often  a  strik- 
ing characteristic.  When  the  patient  is  tranquil,  the  pulse  is  tran- 
quil, but.  the  least  excitement  carries  it  up  ten  or  twenty  strokes 
in  a  minute.  When  the  disease  has  taken  a  strong  hold,  the  pulse 
indicates  it.  It  is  permanently  and  decidedly  accelerated  with  a 
sharp  and  quick  stroke. 

In  the  second  stage  it  increases  in  frequency  often  rising  to 
one  hundred  and  thirty  beats  in  a  minute.  A  slow  pulse  is  a  good 
omen  in  tuberculous  disease,  inasmuch  as  it  is  usually  associated 
with  a  condition  of  the  system  favorable  to  recovery. 

Fever. — In  the  incipient  stage,  this  is  of  an  irritative  character. 
Towards  evening  slight  chills  come  on,  which  are  followed  by 
fever  during  the  night.  It  increases  insidiously,  and  at  length  ter- 
minates in  morning  perspiration.  As  the  disease  advances,  the 
fever  occurs  in  paroxysms,  and  the  heat,  instead  of  being  confined 
to  the  hands  and  feet,  is  more  generally  diffused  over  the  whole 
body.  This  latter  kind  of  fever  is  the  proper  hectic,  being  caused 
by  the  softening  of  tubercles,  and  attended  with  frequent  pulse 
not  so  hard  as  that  which  attends  the  irritative  fever  in  the  first 

stage. 

• 

Night  sioeats. — A  marked  symptom  of  hectic  is  nocturnal  per- 
spiration. This  is  not  proportioned  to  the  severity  of  the  previ- 
ous chill  and  fever.  It  has  a  close  connection  with  sleep.  Louis 
found  the  night  sweats  wanting  in  one-tenth  of  his  cases.  They 
are  most  copious  about  the  time  the  diarrhoea  appears.  These 


320  THORACIC    DISEASES. 

two  symptoms — the  diarrhoea  and  perspirations,  have  been  consid- 
ered supplementary.  Of  this,  however,  there  is  not  good  evi- 
dence. Louis  found  no  reciprocal  influence  existing  between 
them.  At  first  they  usually  are  confined  to  the  head,  neck  arid 
breast.  Subsequently  they  extend  over  the  body  as  the  disease 
approaches  its  termination.  "They  are  often  very  distressing,  pro- 
ducing much  discomfort  and  exhaustion  upon  the  awakening  of 
the  patien|.  They  evidently  depend  upon  a  debility  of  the  capil- 
laries, which  allows  the  watery  portions  of  the  blood  to  pass  with- 
out resistance ;  and  they  occur  during  sleep,  because  then  the 
vital  forces,  and  among  them  contractility  are  at  their  lowest  ebb." 

Emaciation. — This  is  one  of  the  cardinal  symptoms  of  phthi- 
sis. Frequently  it  precedes  the  other  symptoms.  Between  the 
ages  of  forty  and  fifty,  Dr.  James  Clark  found  it  among  the  earli- 
est symptoms  of  phthisis.  Indigestion  is  regarded  by  the  patient 
and  his  friends,  as  one  of  the  principal  causes  of  this  atrophy.  It 
is  frequently  associated  with  ansemia.  There  is  many  times  a  pe- 
culiar physiognomy,  the  cheek  is  pale  and  thin,  and  the  eye  bright. 
Every  organ  in  the  body,  except  the  liver  and  heart,  even  the 
blood  itself,  emaciates.  And  this  is  often  the  first  symptom  no- 
ticed. At  length,  slight  disturbance  is  manifest,  a  little  dyspnoea, 
a  little  chillness  towards  evening,  and  a  tendency  to  cough.  This 
symptom,  emaciation  is  not  always  progressive.  The  patient  may 
gain  flesh,  but  he  soon  loses  it  again  ;  then  perhaps  gains  awhile 
in  weight,  and  so  on  alternately.  This,  however,  is  observable ; 
the  patient  seldom  gains  as  much  flesh  as  he  loses.  There  is  a 
gradual  though  not  continuous  descent.  It  is  true  also  that  while 
there  is  an  increase  of  weight,  the  tubercular  disease  in  the  lungs 
advances  ;  and  while  the  patient  and  friends  are  elated  with  hope 
by  the  apparent  amendment,  a  fatal  termination  steadily  approach- 
es. Loss  of  appetite  and  diarrhoea  very  much  increase  the  ema- 
ciation. 

Diarrhoea. — The  rapidity  of  the  progress  of  consumption  de- 
pends much  upon  this.  With  the  number  of  evacuations,  Louis 
found  that  the  loss  of  strength  and  wasting  corresponded.  This 
fact  should  militate  against  the  employment  of  cathartics  in  phthi- 
sis. "A  tablespoonful  of  castor  oil,"  says  Dr.  James  Clark,  "  I 
have  seen  throw  a  phthisical  patient  into  an  alarming  state  of  de- 


PHTHISIS.  321 

bility."  In  those  who  have  in  health  had  a  costive  habit  of  body 
incipient  phthisis  produces  regularity  .of  the  action  of  the  bowels. 
Diarrhoea  is  usually  confined  to  the  advanced  stages  of  the  dis- 
ease. In  one  eighth  of  the  cases  treated  by  Louis,  diarrhoea  com- 
menced with  the  disease  and  continued  until  its  termination  ;  in 
the  majority  it  occurred  in  the  later  stages,  in  others  during  the 
last  days,  of  life,  and  in  four  out  of  one  hundred  and  twelve  cases, 
it  never  appeared.  The  distress  attending  this  symptom,  .is  often 
severe.  Before  each  evacuation,  there  is  often  a  severe  pain,  and 
immediately  after  it  a  deadly  sensation  of  sinking.  It  has  an  ef- 
fect upon  the  cough  and  expectoration.  The  severity  of  these 
symptoms,  is  usually  in  the  inverse  ratio  to  that  of  the  diarrhoea. 
As  a  diagnostic  sign  it  is  not  of  great  value.  The  nature  of  the 
disease  is  known  by  other  means,  before  this  becomes  fully  devel- 
oped. The  cause  of  the  diarrhoea,  is  the  ulcerationor  the  soften- 
ing of  the  tuberculous  matter  deposited  among  the  coats  of  the 
intestines.  .After  death,  we  find  ulceration  of  the  mucous  mem- 
brane, tuberculous  deposits,  thickening  and  softening,  and  en- 
larged mucous  follicles,  especially  near  the  termination  of  the  ileum 
and  in  the  colon. 

(Edema. — This  is  an  invariable  attendant  of  the  last  stage  of 
phthisis.  In  young  delicate  females,  it  may  supervene  in  the  ear- 
lier stages.  Generally  it  shows  itself  first  in  the  lower  extremi- 
ties, and  is  for  the  most  part  confined  to  them.  In  the  morning 
there  is  sometimes  an  oedematous  appearance  in  the  face.  For 
diagnosis,  this  is  of  no  value ;  but  it  is  a  prognostic  of  ap- 
proaching death. 

Cerebral  and  Nervous  symptoms. — The  intellect  is  usually  un- 
clouded. The  mind  when  the  disease  is  not  complicated  with 
any  affection  of  the  sto'mach  and  liver,  is  hopeful.  The  unwil- 
lingness of  the  patient  to  believe  himself  in  danger,  is  one  of  the 
most  remarkable  symptoms  of  consumption.  Even  those  who 
have  a  good  knowledge  of  consumption,  even  physicians  who 
have  died  of  this  disease,  have  exhibited  the  same  peculiarities  of 
mind.  In  the  first  stage  there  is  a  nervous  irritability,  a  tremb- 
ling of  the  hands,  and  the  mind  is  in  a  peevish  and  irritable  state. 

fiijmptoms  arising  from  derangement  of  the  digestive  and  men- 
strual functions. — The   symptoms  of  dyspepsia  are  not  usually 
41 


322 


THORACIC    DISEASES. 


very  prominent.  Very  often  the  digestive  functions  are  well  per- 
formed until  they  fail  from  constitutional  debility.  The  stomach 
secondarily  becomes  weakened,  and  the  usual  symptoms  of  indi- 
gestion supervene-  In  some  rare  cases  the  stomach  seems  to  be 
primarily  affected.  Its  mucous  membrane,  after  death  presents  a 
"thickened,  mammiUated,  softened"  appearance,  indicative  of  the 
existence  of  chronic  inflammation.  "*At  times,  the  gastric  symp- 
toms become  severe.  Extreme  tenderness  over  the  epigastrium, 
vomiting  of  bile  and  mucus,  and  a  burning  sensation  occur. 

Sexual  symptoms. — In  male  patients  nothing  remarkable  occurs 
in  connection  with  the  sexual  functions.  In  females  it  is  far  oth- 
erwise. The  occurrence  of  pregnancy  arrests  for  awhile  the  de- 
velopment of  tubercles ;  lactation  also  exercises  a  favorable  influ- 
ence over  it.  During  gestation  the  most  alarming  symptoms  of 
phthisis  often  disappear ;  and  it  sometimes  happens  in  young  mar- 
ried women,  that  the  disease  is  warded  off,  many  years  by  child 
bearing  and  nursing  ;  and  sometimes  even  the  predisposition  seems 
to  be  overcome.  After  delivery,  in  most  cases,  its  return  is  speedy, 
and  it  appears  to  compensate  in  the  rapidity  of  its  march,  for  the 
time  during  which  its  progress  was  arrested.  It  is  probable  that 
while  pregnancy  arrests  the  progress  of  phthisis,  it  only  renders  it 
latent,  and  thus  a  mere  temporary  and  not  a  permanent  advantage 
is  gained.  Sometimes  there  is  good  evidence  to  believe,  that  it 
does  not  produce  much  temporary  benefit,  and  the  practitioner  who 
recommends  it  to  his  patient,  may  be  disappointed  in  its  effect. 
"Even  supposing  that  the  progress  of  tubercles  is  retarded  during 
the  existence  of  pregnancy — what  is  the  final  result?  As  soon  as 
delivery  has  taken  place,  the  pulmonary  disease  usually  advances 
with  great  rapidity,  and,  in  addition,  a  ehild  with  a  strong  tuber- 
culous tendency  is  born.  Certainly  there  is  no  great  advantage 
in  these  results,  and  you  will,  I  hope,  be  disposed  to  adopt  the 
opinion  that  I  have  formed, — never  to  advise  pregnancy  to  a  tu- 
berculous patient.  Cases  of  this  kind  will  occur  often  enough, 
and  the  evil  consequences  be  experienced,  without,  or  in  opposi- 
tion to  your  advice."  [Swett's  Lectures,  p.  263.] 

The  condition  of  the  menstrual  function  in  females,  is  a  con- 
sideration of  much  importance.  Many  young  females  cease  to 
menstruate,  they  become  pale  and  feeble,  they  emaciate  somewhat, 


PHTHISIS.  323 

and  the  whole  attention  is  directed  to  the  cessation  of  this  men- 
strual function.  This  abnormal  condition,  is  supposed  to  demand 
for  its  removal,  active  emmenagognes,  which  are  uselessly  pre- 
scribed. The  desired  effect  is  not  obtained,  and  the  symptoms  of 
phthisis  are  gradually 'developed. 

Some  diversity  of  opinion  now  exists  in  regard  to  the  influence 
of  gestation  in  arresting  the  progress  of  phthisis.  "  But  independ- 
ently of  the  general  belief,"  remarks  Dr.  Wood,  '•  my  own  per- 
sonal observation  has  been  such  as  to  render  it  impossible  for  me 
to  have  any  doubt  on  the  subject.  I  have  repeatedly  seen  the  dis- 
ease, even  in  its  somewhat  advanced  stages,  apparently  quite  ar- 
rested on  the  occurrence  of  pregnancy.  Two  cases  are  promin- 
ent in  my  recollection.  The  patients  were  admitted  into  the 
Pennsylvania  Hospital,  with  cavities  in  their  lungs,  and  all  the 
symptoms  of  decided  phthisis.  After  a  time  they  began  to  im- 
prove wonderfully,  and  unaccountably.  The  general  symptoms 
vanished  almost  entirely,  and  they  became  fat  and  quite  healthy 
in  appearance.  This  change  was  found  to  be  coincident  with 
the  occurrence  of  pregnancy." 

Is  the  suppression  of  the  menses  the  cause  of  the  tubercular 
disease  ?  Some  have  thought  that  it  might  lead  to  the  deposit  of 
tubercles  in  the  lungs.  The  menstrual  suppression,  is  for  the 
most  part,  the  effect  of  that  general  debility,  that  deficiency  of  the 
nutritive  properties  of  the  blood,  which  precedes  the  deposition  of 
tubercles.  If  this  theory  is  true,  then  the  treatment,  instead  of 
being  wholly  directed  to  the  restoration  of  the  uterine  function, 
should  be  directed  to  the  removal  of  that  deficient  nutrition,  and 
its  consequent  debility  which  cause  the  menstrual  suppression, 
and  the  tuberculous  deposition.  The  cessation  of  the  menses  is 
sometimes  one  of  the  first,  if  not  the  first  prominent  symptom  of 
phthisis,  and  a  careful  examination  of  the  case  will  often  discover 
this  to  be  the  fact.  Attendant  upon  this  symptom,  there  are,  in 
most  cases,  a  slight  cough,  a  little  chilliness  and  fever,  and  some 
of  the  physical  signs  of  incipient  phthisis.  In  general,  this  func- 
tion continues,  but  decreases  in  quantity,  during  the  early  stage  of 
the  disease.  At  a  later  period,  about  the  time  when  tubercles  be- 
gin to  soften,  it  sometimes  ceases  abruptly.  There  are  cases  in 
which  the  menses  continue  during  the  whole  progress  of  the  dis». 


324  THORACIC    DISEASES. 

ease.     From  a  great  variety  of  causes,  this  function  is  so  liable  to 
derangement,  that  as  a  diagnostic  sign  it  is  not  of  much  value. 

Duration  of  Phthisis. — Tuberculous  phthisis  is  essentially  a 
chronic  disease,  the  range  of  its  duration  being  considerable. 
Cases  have  been  recorded,  which  have  terminated  in  eleven  days, 
while  others  have  lingered  for  twenty  and  even  forty  years. 
These,  however,  are  extreme  cases.  The  majority  of  cases  ter- 
minate in  one  or  two  years,  the  average  duration  being  eighteen 
months.  Various  circumstances  modify  its  duration,  such  as  age, 
sex,  the  constitution  of  the  patient,  the  climate,  season  of  the 
year,  &c.  Louis  found  the  mortality  greater  among  females  dur- 
ing the  first  year  than  among  males,  in  the  proportion  of  forty- 
two  to  thirty.  After  that  time  the  ratio  was  the  same  in  both 
sexes.  When  patients  have  all  the  advantages  derivable  from 
proper  regimen,  change  of  air,  and  good  medical  treatment,  the 
medium  duration  of  phthisis  is  probably  not  much  short  of  three 
years. 


SECTION  III. 
VARIETIES  OF  PHTHISIS. 

Although  tubercular  disease  is  essentially  the  same,  in  its  ana- 
tomical characteristics,  and  constitutional  origin,  it  varies  greatly 
in  the  duration  of  its  course,  and  in  the  external  features  which 
it  assumes.  Five  forms  of  phthisis,  differing  from  the  ordinary 
form  of  the  disease,  are  described  by  Sir  James  Clark.  I  pro- 
pose to  consider  the  acute,  the  chronic,  the  phthisis  of  children, 
and  the  latent. 

Acute  Phthisis. — The  usual  duration  of  phthisis  has  been  sta- 
ted to  be  about  eighteen  months.  In  the  present  variety,  it  fre- 
quently runs  its  course  in  two  or  three  months,  and  sometimes  in 
a  still  shorter  period.  The  acute  form,  admits  of  a  useful  divi-  • 
sion  into  two  varieties  :  The  first  variety,  in  which  the  short 
duration  of  the  disease  depends  chiefly  on  its  violence.  The  sec- 
ond variety,  in  which  the  feeble  powers  of  the  constitution  sink 
under  the  pulmonary  disease,  long  before  it  has  reached  that  stage 
at  which  it  generally  proves  fatal. 


PHTHISIS. 


325 


The  former  variety,  is  manifested  by  symptoms  which,  from 
their  onset,  are  usually  severe  ; — the  pulse  is  quick,  the  heat  of 
the  skin  considerable,  and  the  patient  at  an  early  period  of  the 
disease*,  is  confined  to  his  bed.  All  the  symptoms  of  phthisis  suc- 
ceed each  other  with  great  rapidity.  The  cough  increases,  expec- 
toration goes  quickly  through  its  various  changes,  hectic  fever  is 
violent,  the  morning  perspirations  copious,  and  diarrhoea  hastens  on 
the  patient  to  the  termination  of  life  :  and  in  six  or  eight  weeks 
he  dies  of  what  is  expressively  called  by  the  public,  "  a  galloping 
consumption."  Of  this  variety,  young  people  are  usually  the  sub- 
jects. It  frequently  comes  on  soon  after  the  cessation  of  some 
acute  exanthematous  disease,  as  scarlatina  and  rubeola. 

This  variety,  in  general,  occurs  in  those  persons  whose  consti- 
tutions are  so  highly  tuberculous,  that  any  slight  cause,  easily  ex- 
cites a  deposition  of  tubercles  in  the  lungs. 

In  other  cases,  the  tuberculous  deposits  exist  in  the  pulmonary 
tissue,  anterior  to  the  development  of  any  external  manifest  symp- 
toms. The  disease  is  latent,  and  an  attack  of  haemoptysis,  or  of 
catarrh,  produces  pulmonary  congestion.  Generally  some  inflam- 
mation in  some  part  of  the  lungs  follows,  complicating  the  tuber- 
culous disease.  Henceforth  the  disease  puts  on  its  usual  symp- 
toms, and  rapidly  passes  through  its  course. 

The  latter  variety  is  observed  most  frequently  in  delicate  young 
persons,  and  according  to  Dr.  Clark,  more  frequently  in  females 
than  in  males.  Their  highest  degree  of  health  is  below  the  ordi- 
nary standard.  Possessing  the  tuberculous  cachexia  they  are  hab- 
itually weak,  easily  fatigued,  and  have  a  feeble  circulation  of  the 
blood.  The  symptoms  in  such,  are  not  violent,  the  real  condi- 
tion of  the  patient  is  somewhat  concealed,  and,  before  suspicion 
in  respect  to  the  disease  is  excited,  the  tuberculous  lesion  is  far 
advanced.  Debility  is  considered  the  cause  of  the  accompanying 
symptoms.  The  breathing  is  quick,  cough  troublesome,  and  the 
expectoration  sometimes  tinged  with  blood.  The  pulse  becomes 
rapid,  and  the  morning  perspiration  copious.  The  countenance  is 
pale  and  of  a  leaden  hue,  the  lips  are  of  a  bluish  color,  and  the 
albuginea,  of  a  slightly  dull,  pearly  tint.  Without  much  apparent 
increase  in  symptoms,  such  patients  sometimes  sink  rapidly  under 


326  THORACIC    DISEASES. 

an  attack  of  diarrhoea,  producing  such  extreme  syncope  as  to  ter- 
minate life. 

Chronic  Phthisis. — Laennec  and  Bayle  first  described  the  na- 
ture of  this  variety  of  phthisis.  They  showed  its  identity  with 
the  other  forms  of  the  disease.  The  acute  form,  as  I  have  men- 
tioned, occurs,  for  the  most  part,  in  the  young.  The  chronic 
form  occurs  in  the  old.  After  the  fortieth  year  it  usually  takes 
place.  In  the  acute,  the  hereditary  predisposition  is  strongly 
marked ;  in  the  chronic,  scarcely  apparent ;  or  if  so,  it  has  been 
kept  in  check  by  a  train  of  causes,  adverse  to  tuberculous  deposi- 
tion. The  .disease,  in  most  cases,  is  scarcely  cognizable  in 
the  early  stage.  The  patient  may  be  a  little  languid,  have  a 
slight  cough,  attended  by  no  fever  or  anorexy.  He  is  a  little  dys- 
peptic, the  stomach  is  the  organ  blamed  for  his  indisposition.  A 
visit  into  the  country,  change  of  air,  and  good  food,  dispel  for  a 
while,  all  appearances  of  the  disease. 

The  next  winter  and  spring,  however,  cause  a  return  of  the 
old  symptoms.  So  the  disease  may  alternately  recede  and  ad- 
vance, during  a  long  period.  But  at  last,  after  an  attack  of  ca- 
tarrh, it  assumes  more  of  the  appearances  of  phthisis.  Cough, 
dyspnoea,  expectoration,  emaciation  and  fever  all  arise,  and  threat- 
en to  terminate  existence.  From  all  these  symptoms,  sometimes 
he  recovers,  and  during  the  summer  months,  enjoys  a  tolerable 
degree  of  health.  In  general,  such  patients  while  attending  to 
business,  are  subject  to  occasional  attacks  of  catarrh,  pleuritis,  or 
pneurnonitis.  Physical  exploration  of  the  chest  will  seldom  fail 
to  reveal  the  true  condition  of  the  lungs.  The  respiratory  move- 
ments are  more  limited,  percussion  under  the  clavicles  is  dull,  the 
voice  more  resonant  than  natural,  and  pectoriloquy  is  sometimes 
present.  In  such  cases,  cavities  are  formed,  some  of  which  have 
been  emptied  of  their  contents,  others  are  in  progress  of  cure,  or 
are  actually  cicatrized.  Regular  and  temperate  habits  may  often 
cause  the  patient  to  live  to  the  ordinary  age  of  man. 

Ordinary  causes,  those  which  would  have  either  no  effect  or 
but  a  slight  one  upon  the  healthy  constitution,  give  rise  to  the 
most  serious  diseases  of  the  thorax.  The  influenza  which  pre- 
vailed in  the  summer  of  1832,  and  spring  of  1833,  proved  fatal 
to  many  such  invalids.  How  can  we  account  for  this  slow  pro- 


PHTHISIS.  327 

gress  of  the  disease,  when  no  exciting  causes  develop  it,  and  its 
speedy  termination  when  such  causes  exist?  Evidently,  the  con- 
stitutional predisposition  to  such  a  disease  is  slowly  induced  by 
certain  long-continued  habits,  and  not  by  any  hereditary  influence. 

That  this  view  of  the  subject  is  true,  seems  to  be  evinced  by 
the  great  prevalence  of  this  form  of  phthisis  among  persons  in 
the  upper  ranks  of  society.  In  those  who  labor,  the  acute 
forms  are  more  prevalent.  A  form  of  phthisis  somewhat  chronic 
in  its  nature,  is,  however,  occasionally  observed  in  the  lower 
ranks  of  society.  One  attack  of  pneumonitis,  or  pleuritis,  or  ca- 
tarrh succeeds  another,  until  the  lungs  become  completely  adher- 
ent to  the  parietes  of  the  chest,  the  thorax  scarcely  moving  dur- 
ing respiration.  Post  mortem  examinations  of  those  who  die  of 
this  form  of  phthisis,  reveal  a  variety  of  pathological  changes,  in 
one  part  inflammation  has  left  its  morbid  products,  in  another  tu- 
bercles in  their  various  stages  of  development  have  disorganized 
the  pulmonary  tissues.  This  form  of  phthisis,  from  practical  con- 
siderations, should  be  studied  more  than  other  varieties.  In  the 
first  place,  because  it  is  liable  to  be  overlooked  until  it  has  made, 
considerable  progress,  and  remedial  agents  have  become  compara- 
tively ineffectual  in  its  cure.  And  secondly,  it  demands  thorough 
investigation,  because,  in  this  form  more  than  in  others,  time  is 
given  for  the  operation  of  remedies,  and  for  effecting  its  perma- 
nent removal  by  the  formation  of  proper  habits  of  life.  The  in- 
fluence of  its  exciting  causes,  may  be  warded  off,  all  derange- 
ments of  the  digestive  organs,  all  irregularities  of  the  circulation 
of  the  blood,  can  be  removed  before  tubercles  are  deposited  in  the 
lungs. 

Phthisis  in  Infancy  and  Childhood. — Phthisis  is  more  common 
in  childhood  and  infancy,  than  was  once  supposed.  Dr.  Guersent, 
one  of  the  physicians  to  the  Hospital  des  Enfans  Malades', — an 
Institution  appropriated  to  the  treatment  of  patients  between  the 
ages  of  one  and  sixteen  years — gives,  as  the  result  of  his  obser- 
vations, that  five-sixths  of  those  who  die  in  that  establishment, 
are  more  or  less  tuberculous.  [Le  Blond,  sur'me  espece  de  phthi- 
sic particuliere  aux  enlaiis.  Paris,  1824.] 

Early  in  life  its  existence  is  manifested  by  symptoms  somewhat 
different  from  those  of  adults.  The  cough  occurs  in  -paroxysms ; 


328 


THORACIC    DISEASES. 


hectic,  expectoration  and  hemorrhage  from  the  lungs,  are  not  so 
apparent.  The  tuberculous  cachexia,  rapid  pulse  and  breathing, 
emaciation  and  derangements  of  the  digestive  organs,  tumid  abdo- 
men and  irregular  action  of  the  bowels,  at  one  time  constipated, 
at  another,  affected  with  diarrhosa,  and  the  pale  unnatural  color  of 
the  evacuations,  point  out  to  the  physician,  the  nature  of  the  dis- 
ease. • 

In  children,  the  mesenteric  glands  are  more  subject  to  disease 
than  in  adults.  But  the  most  frequent  seat  of  tuberculous  affec- 
tions, is  the  bronchial  glands,  and  next  in  frequency,  the  lungs. 
The  relative  frequency  of  tubercles  in  the  bronchial  glands  of 
children  compared  with  the  lungs,  is  not  less  than  five  to  four; 
which  is  of  course  more  than  reversed  after  the  age  of  puberty. 

The  relative  ratio  existing  between  the  frequency  of  tubercu- 
lous disease  in  the  bronchial  glands,  lungs  cervical  and  mesenteric 
glands  is  as  the  numbers  49.  38.  26.  25.  [Journal  de  progress  des 
sciences  Medicales,  t.  ii.  p.  93.] 

Respecting  the  development  of  tubercles  in  the  bronchial  glands, 
Dr.  Gerhard,  says  "it  occurs  nearly  as  in  other  solid  structures  of 
the  body ;  scattered  points  of  tuberculous  substances  are  gradu- 
ally deposited  in  the  structure  of  the  glands,  surrounded  by  the 
original  tissue,  which  remains  for  a  considerable  time  nearly  in 
the  healthy  state  ;  sometimes,  however,  it  is  swollen  and  more 
vascular  than  usual,  but  more  frequently  it  is  quite  pale,  and  in- 
filtrated with  the  gelatinous  substance  which  is  in  many  cases  the 
early  stage  of  tuberculous  matter.  As  the  quantity  of  tubercle 
increases,  that  of  glandular  structure  gradually  becomes  less,  until 
the  whole  tissue  of  the  gland  is  absorbed,  and  is  replaced  by  tu- 
bercle. It  is  then  much  larger  than  the  original  gland,  and  the 
capsule  which  encloses  it,  gradually  thickens,  during  the  process 
of  softening.  After  softening  has  followed,  adhesion  occurs  be- 
tween the  glands  and  the  nearest  large  bronchial  tube,  so  that  the 
contained  matter  is  evacuated  by  an  opening  into  it.  In  most  in- 
stances, however,  no  softening  occurs,  but  the  tuberculous  matter 
becomes  hard  and  dry,  and  is  converted  into  a  calcareous  substance, 
surrounded  by  a  capsule.  This  substance  often  becomes  ex- 
tremely hard  and  solid,  and  generally  remains  in  this  state  during 
life.  The  tuberculous  disease  of  the  bronchial  gland,  is,  there- 


PHTHISIS.  329 

fore,  much  less  unfavorable  than  that  of  the  lungs,  and  is  essen- 
tially curable." 

The  symptoms  of  tubercles  in  the  bronchial  glands  are  very 
obscure.  They  can  be  recognized  better  by  the  existence  of  the 
tuberculous  cachexia,  than  by  any  other  means  of  diagnosis.  Since 
this  state  of  the  system  rarely  exists  in  children  without  a  deposi- 
tion of  tubercles  in  those  glands,  we  may  safely  predict  the  exist- 
ence of  the  local  when  the  constitutional  disease  is  present. 

Respiration  is  extremely  feeble  in  one  or  both  lungs,  while  per- 
cussion is  quite  resonant.  The  only  permanent  sign  is  the  feeble- 
ness of  respiration,  which  is  often  caused  by  the  contraction  of 
the  larger  tubes  in  consequence  of  the  pressure  of  the  enlarged 
glands.  Expiration  is  at  times  wheezing  and  protracted.  The 
glands  sometimes  enlarge  so  as  to  produce  a  swelling  on  the  sides 
of  the  trachea.  This,  however,  is  rare.  In  case  the  child  expec- 
torates tuberculous  matter,  and  no  symptoms  of  cavities  in  the 
lungs  are  present,  the  diagnosis  is  nearly  certain. 

Latent  Phthisis. — Of  phthisis  there  are  cases  in  which  the 
rational  symptoms,  such  as  cough,  expectoration,  haemoptysis, 
pain  and  dyspnoea,  do  not  exist.  The  development  of  tubercles 
is  slow,  it  being  from  six  months  to  two  years  before  their  exist- 
ence is  indicated  by  any  local  symptom.  Out  of  one  hundred 
and  twelve  cases  of  phthisis,  Louis  found  eight  in  which  the  dis- 
ease was  latent.  By  closely  examining  the  history  of  many  cases 
of  phthisis,  we  find  satisfactory  evidence,  that  tuberculous  disease 
had  commenced  in  the  lungs  from  one  to  two  years  before  proper 
attention  was  given  to  it,  or  its  nature  was  understood. 

The  constitutional  symptoms  should  excite  the  suspicion  of 
the  practitioner.  Whenever  these  are  present,  without  any  visi- 
ble cause,  local  disease  must  be  their  source  of  development. 
Under  such  circumstances,  let  an  examination  of  the  chest  be 
made;  and  very  probably  the  seat  of  the  difficulty  will  be  found 
in  tuberculous  disease.  An  attentive  observer,  will,  in  general, 
be  able  to  detect  it  by  the  physical  signs,  by  the  general  appear- 
ance of  the  patient,  and  by  his  peculiar  diathesis. 

But  difficulties  in  diagnosis  sometimes  occur,  which  are  not  so 
readily  overcome.  The  physical  signs,  as  well  as  the  rational 
symptoms,  may  be  obscure,  indistinct,  or  even  absent  When 
42 


330  THORACIC    DISEASES. 

they  are  so,  repeated  examinations  of  the  chest  should  be  made, 
By  so  doing  the  true  nature  of  the  case  will  finally  appear.  This 
variety  according  to  Dr.  James  Clark,  is  most  frequently  met  with 
in  the  latter  part  of  life,  but  it  is  not  wholly  confined  to  any  pe- 
riod. Sometimes  attacks  of  phthisis  cease,  the  patient  becomes 
comparatively  well,  and  years  elapse  before  any  of  its  manifest 
symptoms  again  show  themselves. 

Laennec  affirms,  "that  the  greater  number  of  cases  of  phthisis 
are  latent  at  the  beginning,  since  nothing  is  more  common  than 
to  find  numerous  miliary  tubercles  in  lungs  otherwise  quite 
healthy,  and  in  subjects  who  have  never  had  any  symptoms  of 
consumption.  On  the  other  hand,  from  considering  the  great 
number  of  phthisical  and  other  subjects  in  whom  cicatrices  are 
found  in  the  summit  of  the  lungs,  it  is  more  than  probable  that 
hardly  any  person  is  carried  off  by  a  first  attack  of  phthisis.  Since 
the  adoption  of  this  opinion  on  anatomical  grounds,  it  has  fre- 
quently appeared  quite  clear  to  me,  from  carefully  comparing  the 
history  cf  my  patients  with  the  appearances  on  dissection,  that 
the  greater  number  of  those  first  attacks  are  mistaken  for  slight 
colds,  and  that  others  are  quite  latent,  being  unaccompanied  with 
either  cough  or  expectoration,  or  indeed  with  any  symptom  suffi- 
cient to  impress  the  memory  of  the  patients  themselves." 

If  this  opinion  of  Laennec  is  true,  it  seems  very  important  that 
the  physician  should  be  able  to  detect  the  disease  in  its  nascent 
state.  Were  he  able  so  to  do,  appropriate  remedies  could  be  im- 
mediately prescribed,  the  salutary  effects  of  which  would  so  for- 
tify the  system  against  repeated  attacks,  as  to  secure  to  the  pa- 
tient health  and  the  enjoyments  of  life.  If,  then,  we  see  a  patient 
who,  on  the  slightest  exposure  takes  cold,  who  is  thin,  and  pale, 
whose  food  affords  but  little  nourishment  on  account  of  a  de- 
ranged state  of  the  digestive  organs,  whose  form  and  tempera- 
ment are  favorable  to  the  production  of  phthisis,  latent  consump- 
tion should  be  looked  for,  even  though  there  are  no  rational 
symptoms  manifested. 

Certain  conditions  of  the  system  disguise  phthisis.  Of  these, 
one  is  pregnancy  of  which  I  have  already  written.  An  attack  of 
mania  is  another  condition  which  arrests  the  pulmonary  disease. 
Dyspepsia  sometimes  draws  off  the  attention  from  the  phthisical 


PHTHISIS.  331 

condition  of  the  lungs.  Diarrhoea  is  another  disease  which  dis- 
guises phthisis.  Not  unfrequently  when  the  intestines  are  sup- 
posed to  be  extensively  diseased,  on  account  of  the  presence  of 
diarrhoea,  a  post-mortem  examination  reveals  the  existence  of  tu- 
bercles in  the  lungs.  In  such  cases,  the  primary  affection  is  gen- 
erally in  the  lungs,  the  diarrho3a  is  for  the  most  part  secondary. 


SECTION  IV. 
COMPLICATIONS. 

Tubecular  phthisis  affects  nearly  every  organ,  but  plays  its  most 
conspicuous  part  in  the  lungs.  In  them  is  its  focus,  and  from 
them  it  seems  to  radiate.  To  this  there  are  exceptions.  But 
were  we  to  consider  the  aggregate  number  of  deaths  from  phthi- 
sis, whether  occurring  in  childhood,  during  adolescence,  in  middle 
life  or  in  old  age,  we  should  find  that  in  a  majority  of  instances, 
the  lungs  were  primarily  affected,  and  other  organs  secondarily. 
Other  diseases  so  disguise  its  existence  and  so  complicate  with  it, 
that,  in  order  to  arrive  at  perspicuity  in  diagnosis,  it  is  necessary 
to  consider  the  more  important  of  those  complications. 

Cerebral  Complications. — The  phthisis  of  adults  is  usually  at- 
tended with  no  great  derangement  of  the  cerebral  functions.  In 
children,  however,  it  is  different.  The  tuberculous  meningitis  of 
children  is  one  of  the  most  interesting  lesions  produced  by  tuber- 
cles. In  them  this  form  of  cerebral  disease  is  sometimes  devel- 
oped, antecedent  to  pulmonary  derangements.  It  may  be  recog- 
nized by  the  severe  pain  in  the  head,  followed  by  vomiting,  pros- 
tration of  strength,  agitation  alternating  with  stupor,  convulsive 
movements,  paralysis,  and  coma ;  and,  by  the  termination  of  the 
case  in  death,  while  the  thoracic  symptoms  seem  to  diminish. 
The  tuberculous  deposit  is  found,  sometimes,  in  the  pia-mater,  at 
the  base  of  the  brain,  and  in  its  substance.  Effusion  of  transpar- 
ent, or  turbid  serum  into  the  ventricles,  is  in  some  cases  noticed. 
The  disease  called  acute  hydrocephalus,  is  the  effect  of  the  tuber- 
culous disease,  attacking  the  membranes  of  the  brain ;  and  chronic 
hydrocephalus,  has  probably  an  intimate  connection  with  tuber- 
cular deposition  in  the  cerebral  substance. 


332  THOHACIC    DISEASES. 

Ulceration  of  the  Epiglottis,  of  the  Larynx  and  of  the  Trachea. 
— The  epiglottis,  in  the  latter  periods  of  the  disease,  is  frequently 
affected,  and  simultaneously  with  it,  the  larynx.  The  lingual 
surface  of  the  epiglottis  is  rarely  ulcerated.  Louis  mentions  only 
one  case  of  this  kind.  The  symptoms  by  which  it  may  be  known, 
are  pain  in  the  region  of  the  os  hyoidcs,  and  difficult  deglutition, 
fluids  being  ejected  through  the  nostrils  in  the  attempt  to  swal- 
low. Sometimes  there  is  oedema  of  the  epiglottis.  The  larynx 
frequently  ulcerates,  the  attending  symptoms  often  being  so  prom- 
inent, as  to  lead  the  inexperienced  to  give  a  wrong  location  to  the 
whole  difficulty,  and  not  to  suspect  any  pulmonary  disease.  That 
variety  of  phthisis  which  is  called  laryngeal,  is  nothing  more  than 
pulmonary  consumption  accompanied  by  a  morbid  condition  of 
the  larynx,  the  symptoms  of  which  predominate,  and  mask  those 
of  the  pulmonary  disease,  upon  which  the  emaciation,  hectic  fever, 
night-sweats,  and  other  symptoms  of  phthisis  chiefly  depend.  A 
constant  symptom  of  ulceration  of  the  larynx,  is  hoarseness, 
which  often  terminates  in  complete  aphonia.  The  cough  has  a 
harsh  grating  sound,  and  sometimes  resembles  a  kind  of  whist- 
ling. 

The  symptoms  of  ulceration  of  the  tracbea.  are  very  obscure. 
Louis  saw  only  one  patient  in  which  heat  and  obstruction,  was 
complained  of  in  the  region  of  the  sternum.  Ulceration  of  the 
trachea  is  almost  exclusively  confined  to  phthisis,  and  the  side 
of  the  trachea  corresponding  with  the  lung,  in  which  the  greater 
amount  of  disease  exists,  is  most  frequently  and  severely  affected. 

The  bronchial  membrane  presents  an  abnormal  appearance.  It 
is  reddened,  thickened  and  sometimes  ulcerated.  This  condition 
of  the  membrane  is  chiefly  confined  to  the  surface  of  those  tubes 
which  communicate  with  caverns.  The  sputa  passing  over  the 
surfaces  of  the  lining  membranes  of  the  bronchi,  trachea  and 
larynx,  according  to  the  opinion  of  Louis,  cause  the  membranous 
disease. 

These  ulcers  seldom  penetrate  below  the  mucous  membrane, 
although  they  sometimes  involve  tlje  muscular  and  cartilaginous 
rings  of  the  trachea,  the  vocal  cords,  the  arytenoid  cartilages  and 
epiglottis.  That  these  lesions  are  closely  connected  with  phthi- 
sis, is  made  evident  by  statistics.  Out  of  one  hundred  and  twen- 


PHTHISIS.  333 

ty-two  patients  who  died  of  chronic  diseases,  not  phthisical,  Louis 
found  only  one  case  of  ulceration  of  the  epiglottis  and  larynx ; 
whereas,  in  those  who  died  of  phthisis,  he  found  ulceration  of  the 
epiglottis  and  larynx  in  one-fifth,  of  the  trachea,  in  one-third  of 
the  consumptive  cases  which  came  under  his  observation.  These 
lesions,  are  found  much  more  frequently  in  males  than  in  females. 

Affections  of  the  Pleura. — In  the  article  on  pleuritis,  I  have 
spoken  of  the  connection  of  tubercles  with  pleuritic  inflammation. 
That  this  connection  is  intimate,  morbid  anatomy  has  clearly  de- 
monstrated. When  these  .adhesions  are  extensive,  they  some- 
times present  the  appearance  of  a  cap,  composed  of  semi-cartilag- 
inous crusts,  covering  the  apices  of  the  lungs,  in  which  tubercu- 
lous matter  is  sometimes  deposited. 

Diseases  of  the  Abdominal  Viscera  connected  with  Phthisis. 
— During  the  course  of  tubercular  consumption,  the  mucous  mem- 
brane of  the  alimentary  canal,  is  usually  affected.  Andral  re- 
marks, "  that  softening  of  the  mucous  membrane  of  the  stomach, 
hyperaemia  of  the  different  portions  of  the  intestines,  accompan- 
ied in  many  instances  by  a  development  of  tubercles,  are  all  of 
such  frequent  occurrence  in  phthisis,  that  they  may  be  fairly  con- 
sidered as  constituent  parts  of  the  disease. 

Morbid  condition  of  the  Stomach. — Inflammation  of  the  stom- 
ach occurs  at  a  late  stage  in  the  disease,  and  gives  rise  to  anorexia, 
heat,  pain,  and  tenderness  in  the  epigastrium;  and,  in  some  cases, 
to  nausea  and  vomiting.  This  condition  of  the  stomach,  accord- 
ing to  Louis,  was  an  attendant  of  phthisis  in  eight  cases  out  of 
one  hundred  and  twenty-three.  When  the  symptoms  arise  from 
gastritis,  there  are  anorexia,  pain  in  the  epigastrium,  increased  by 
pressure,  and  other  symptoms  of  gastric  derangement ;  but  when 
from  the  cough*  the  appetite  is  usually  good,  no  epigastric  tender- 
ness or  pain  is  present,  and  the  vomiting  comes  on  early  in  the 
disease. 

Another  variety  of  gastric  derangement  sometimes  exists.  It  is 
known  by  pain  and  vomiting.  But  little  food  can  be  borne  on 
the  stomach  ;  sometimes  not  more  than  a  spoonful  of  fluid  two  or 
three  times  a  day. 

Ulcerations  of  the  Intestines. — The  location  of  the  intestinal 
lesions,  is  in  the  ileum,  near  that  part  which  is  adjacent  to  the 


334  THORACIC    DISEASES. 

mesentery,  and  where  the  glandulae  agminatse  are  most  numerous. 
In  the  colon,  the  ulcerations  are  somewhat  irregular,  often  extend- 
ing to  contiguous  tissues,  and  coalescing  together.  Louis  found 
them  extending  to  the  length  of  nine  inches.  Casteris  paribus, 
the  more  early  and  extensive  these  ulcerations  of  the  in  test  hies, 
the  more  speedy  is  the  termination  of  the  disease.  The  cause  of 
this  is  found  in  the  great  emaciation  produced  by  the  diarrhoea 
which  is  attendant  upon  these  abdominal  lesions.  The  mesen- 
teric  glands  are  very  often  involved  in  the  constitutional  disease. 
In  about  half  of  the  cases  of  the  phthisis  of  children,  they  are 
affected ;  in  about  one  half  of  the  cases  in  adults. 

When  ulcerations  of  the  intestines,  cause  perforation,  the  result 
is  acute  peritonitis,  the  symptoms  of  which  are  often  obscure,  but 
rapid.  Usually  there  is  a  tumid,  tympanitic  abdomen,  with  or 
without  pain  and  tenderness,  a  sudden  prostration,  a  very  rapid 
pulse,  and  speedy  collapse  which  soon  terminates  in  death.  A 
chronic  form  of  peritonitis  is  sometimes  the  result  of  tuberculous 
disease,  and  a  concomitant  of  phthisis.  Its  existence  may  be 
known  by  the  pain  in  the  abdomen,  not  very  severe,  but  wander- 
ing, moderate  in  degree,  often  transient,  and  followed  by  tympani- 
tic distension  from  gas  in  the  intestines. 

"After  a  time  the  distension  diminishes,  from  an  absorption-of 
the  liquid  effusion,  and  from  a  partial  removal  of  the  gas,  and  the 
abdomen  remains  enlarged  with  a  dough-like  feeling,  or  with  firm 
ridges,  giving  the  sensation  of  an  unequal  firmness  on  pressure ; 
in 'addition  to  these  local  symptoms,  the  constitutional  symptoms 
of  tuberculous  disease  are  present, — emaciation  and  loss  of 
strength,  hectic,  accelerated  pulse,  and  especially,  if  the  rational 
or  physical  signs  of  tuberculous  disease  of  the  lungs  exist,  we 
need  have  no  hesitation  in  referring  the  abdominal'symptoms  to  a 
tuberculous  peritonitis." 

"After  death  we  find  our  diagnosis  confirmed  by  an  abundant 
deposit  of  tubercles  in  the  peritoneal  cavity — false  membranes 
loaded  with  tubercles  and  gluing  the  folds  of  the  intestines  to- 
gether. Sometimes  we  find  tubercles  under  the  peritoneum,  and 
perhaps  a  considerable  effusion  of  serous,  sero-purulent,  or  even 
purulent  matter  in  the  cavity  of  the  abdomen."  [Swett's  Lectures.] 

Disease  of  the  Liver.     A  remarkable   fact  in   the   history   of 


PHTHISIS.  335 

phthisis  is  the  fatty  degeneration  of  the  Liver.  To  phthisical  dis- 
ease it  is  peculiar.  Oat  of  forty-nine  cases  Louis  found  forty- 
seven  in  which  this  condition  was  present.  Out  of  two  hundred 
and  thirty  that  died  of  other  diseases,  there  were  only  nine.  From 
these  statements  of  the  French  Pathologist,  it  appears  that  a  de- 
posit of  fat  in  the  liver  is  an  almost  constant  attendant  upon 
phthisis.  The  presence  of  the  fatty  matter  may  be  known  by 
cutting  the  liver  and  observing  the  appearance  of  the  scalpel ;  or 
by  putting  a  piece  of  it  upon  tissue  paper,  and  applying  thereto  a 
moderate  heat,  when  the  stain  of  melting  fat  will  appear;  or  by 
placing  portions  of  the  liver  in  ether,  which,  after  evaporation, 
will  leave  particles  of  fat.  With  the  microscope  we  can  detect 
its  existence.  This  condition  of  the  liver  is  marked  by  a  pale 
yellowish  color,  by  its  enlargement  and  by  its  softened  texture. 

It  is  most  common  in  females  and  in  drunkards.  Why  this  is 
so,  it  is  difficult  to  explain.  The  functions  of  the  liver  are  but 
little  impaired,  when  a  large  portion  of  its  tissue  is  converted  into 
fat. 

Another  condition  of  the  liver,  occurring  just  before  the  devel- 
opment of  tubercles,  is  cirrhosis.  This  is  most  frequent  when 
phthisis  occurs  in  countries  where  intermittents  prevail. 

Fistula  in  Ano. — This  affection  frequently  exists  in  phthisis, 
and  is  thought  by  some  authors  to  be  connected  with  it.  Louis, 
Andral,  and  Dr.  Clark  do  not  find  this  opinion  satisfactorily  con- 
firmed. The  latter  author  suggests  that  its  dependence,  may  be 
on  the  venous  plethora  of  the  abdomen,  which  often  precedes 
pulmonary  consumption.  Dr.  Morton,  on  the  contrary,  thinks, 
from  facts  which  have  come  under  his  observation,  that  there  may 
be  a  connection.  Dr.  Gerhard  also  recognizes  the  existence  of 
such  a  connection,  and  says  that  cases  of  fistula  ought  very  rarely 
to  be  treated  by  a  surgical  operation.  "I  have  often,"  he  remarks, 
"thought  that  I  was  rendering  an  important  service  to  patients  by 
preventing  them  from  allowing  industrious  surgeons  to  tamper 
with  cases  of  the  kind  mentioned." 

Differential  Diagnosis. — While  treating  of  the  general  course 
of  phthisis  I  described  the  more  important  symptoms  and  their 
bearing  in  the  formation  of  a  correct  diagnosis.  Occasionally  the 
varieties  and  complications  of  the  disease  increase  the  difficulty 


336  THORACIC    DISEASES. 

of  detecting  its  existence,  and,  therefore,  I  deem  it  best  to  take  a 
summary  view  of  the  more  common  sources  of  diagnostic  error. 

In  the  first  stage  the  greater  amount  of  accurate  discernment  is 
necessary.  Before  the  general  symptoms  are  fully  developed, — 
the  physical  signs  at  the  same  time  being  scarcely  observable, — 
the  diagnosis  must  be  dependent  upon  the  temperament,  the  con- 
stitution and  the  nature  of  the  predisposing' causes,  together  with 
the  slightest  appearances  of  constitutional  debility,  hectic  fever, 
cough,  and  haemoptysis.  Seldom  do  all  of  these  symptoms  occur 
in  conjunction,  and  hence  a  diagnostic  error  often  results  from 
the  greater  dependence  upon  several  variable,  uncertain  symptoms 
than  upon  one  or  two  nearly  pathognomonic.  The  first  appearance 
of  haemoptysis  in  a  scrofulous  constitution  is  a  very  suspicious 
symptom,  and,  if  it  occurs  alone,  with  no  other  external  phenom- 
ena, it  should  be  considered  of  much  more  value,  than  the  hectic 
fever,  the  excited  pulse  and  dyspnrea.  It  is  very  seldom  that  sev- 
eral symptoms  do  not  exist  coetaneously.  After  one  prominent 
one  appears  others  soon  accompany  it,  and  make  the  diagnosis 
more  and  more  certain. 

Bronchitis  sometimes  complicates  with  phthisis,  the  symptoms 
of  the  former  sometimes  simulating  those  of  the  latter.  In  the 
former  there  is  more  fever,  in  its  first  stage  more  expectoration, 
but  no  haemoptysis.  Bronchitis  gives  rise  to  the  development  of 
the  physical  signs  in  the  lower  parts  of  the  chest,  but  phthisis  in 
the  apices  of  the  lungs.  But  in  some  cases  miliary  tubercles 
equally  disseminated  through  the  lungs  give  rise  to  symptoms 
almost  identical  with  those  of  bronchitis.  Under  such  circum- 
stances we  have  in  phthisis  the  continued  presence  of  the  mucous 
or  sub-mucous  rales,  emaciation,  night-sweats,  unchanged  by  the 
treatment  which  would  prove  decidedly  efficacious  in  bron.- 
chitis. 

In  the  advanced  stage  of  phthisis,  the  existence  of  cavities  and 
their  attending  physical  signs,  the  steady  advance  of  emaciation, 
the  pulmonary  hemorrhage,  and  the  non-appearance  of  these 
symptoms  in  bronchitis  will  afford  sufficient  evidence  to  estab- 
a  correct  diagnosis.  Phthisis,  too,  is  most  often  accompanied 
with  a  "hopeful  state  of  the  mind,  but  bronchitis  with  despon- 
pency. 


PHTHISIS.  337 

CJironic  bronchitis  may  in  some  instances  resemble  phthisis. 
This  form  cf  the  disease  usually  occurs  in  old  age — is  attended 
by  morning  expectoration,  the  sibilant  rale,  dyspnoea,  and  slight 
fever  after  exposure  to  cold.  Sometimes  emaciation,  hectic,  and 
great  debility  attend  it.  In  such  cases,  the  physical  signs  indi- 
cate the  nature  of  the  malady.  The  sub-clavicular  regions,  give 
a  good  sound  on  percussion,  and  to  the  ear  the  respiratory  mur- 
mur. While  over  the  sternal  region,  and  the  lower  part  of  the 
chest,  the  sibilant  or  mucous  rale  will  frequently  be  heard. 

There  is  a  complication  of  this  disease,  which  when  it  occurs 
— and  its  occurrence  is  very  rare, — will  puzzle  the  most  experi- 
enced physician.  The  physical  signs  then  become  deceptive. 
It  is  the  complication  of  chronic  bronchitis  with  dilatation  of  the 
bronchi.  As  before  remarked,  dilatation  of  the  bronchi  may  pro- 
duce a  cavity,  and  that  cavity  may  be  partly  filled  with  liquid  ; 
and  we  have  the  cavernous  respiration,  and  the  gurgling  rale.  In 
case  there  is,  around  this  dilated  portion  of  the  bronchi,  pulmon- 
ary congestion,  then  slight  hemorrhage  sometimes  supervenes, 
and  thus  simulates  hemoptysis  from  tuberculous  disease.  And 
again,  these  dilatations  sometimes  occur  near  the  apices  of  the 
lungs,  and  thus  still  more  nearly  simulate  phthisis.  When  the 
complication  exists  it  is  almost  impossible  to  form  a  correct  diag- 
nosis. 

Emphysema  sometimes  causes  difficulty  in  the  formation  of  a 
correct  diagnosis.  If  existing  at  the  summit  of  the  lung,  it  be- 

o  o  o  / 

comes  more  resonant  than  normal,  and  consequently  the  healthy 
lung  by  contrast,  seems  to  be  dull  on  percussion.  But  this  con- 
dition of  the  air-vesicles,  gives  rise  to  a  feebler  respiratory  sound, 
than  is  heard  over  the  healthy  lung  ;  so  that  the  coincidence  of 
great  resonance  on  percussion,  with  an  absence  of  the  respiratory 
murmur  on  one  side,  while  on  the  other  the  respiratory  sound  is 
normal,  with  apparent  dullness, — though  not  real, — will  afford  dis- 
tinguishing characteristics  of  the  nature  of  the  internal  lesion. 

Pneiunonitis,  in  a-  chronic  form,  may  sometimes  simulate  phthi- 
sis. The  distinctive  symptoms,  are  the  crepitant  rale  followed 
by  bronchial  respiration,  the  rusty  sputa,  the  location -of  the  pneu- 
monitis  which,  very  rarely  attacks  the  upper  lobes  of  the  lungs; 
the  absence  of  the  hemoptysis  of  the  expectoration  of  cousump- 
43 


338  THORACIC    DISEASES. 

lion,  of  the  night-sweats,  and  of  the  febrile  exacerbations  arid  re- 
missions. But  suppose  the  pneumonitis  to  attack  the  upper  lobes, 
as  an  effect  of  tubercular  deposition.  How  then  can  the  kind  of 
lesion  be  determined  ?  With  the  rusty  sputa,  is  mingled  an  unu- 
sual amount  of  blood,  which  arises  from  slight  haemoptysis.  The 
crepitant  rale  is  present,  and  after  the  pneumonitis  has  subsided, 
some  physical  signs  remain  behind.  This  latter  effect  is  strongly 
indicative  of  tuberculous  disease ;  for  pneumonitis  leaves  no  phy- 
sical signs  after  it.  And  so  it  is  with  bronchitis.  The  mucous 
rale  which,  when  it  exists  at  the  base  of  both  lungs,  unattended 
by  dullness  on  percussion,  indicates  the  presence  of  bronchitis, 
may  be  heard  only  in  one  lung,  and  in  its  apex  in  case  phthisis  is 
present.  When  this  is  the  case,  and  especially  if  the  pulmonary 
disease  is  chronic,  the  existence  of  tubercles  is  soon  evinced. 
The  mucous  rale  exists  at  the  apices  of  the  lungs,  in  which  case 
tubercles,  of  course,  are  known  to  be  deposited  in  both.  This 
physical  sign  marks  the  period  of  tuberculous  softening.  When 
this  process  commences,  the  contiguous  bronchi  are  inflamed,  a 
mucous  secretion  is  its  effect,  which  gives  rise  to  the  mucous  rale, 
as  the  air  passes  through  the  tubes  partially  filled  with  the  secre- 
tion. When  this  sound  is  heard  at  the  place  which  tubercles  usu- 
ally occupy,  it  removes  doubt,  and  establishes  a  true  diagnosis. 

But  there  are  on  record,  cases  of  pneumonitis  of  the  superior 
lobes  of  the  lung's,  which  give  rise  to  a  mucous  rale  that  deceives 
the  attending  physicians.  This  result,  however,  may  be  obvia- 
ted by  attending  to  the  history  of  the  disease  ;  pneumonitis  pas- 
sing rapidly  through  its  different  stages;  phthisis  progressing 
slowly,  and  surely  to  a  fatal  termination. 


SECTION  V. 
CAUSES   OF   PHTHISIS. 

Inquiries  into  the  causes  of  phthisis  have"  been  very  extensive, 
and  have  brought  to  light  much  useful  knowledge  respecting  its 
prevention.  But  certainty  is  not  as  yet  attained,  and  many  influ- 
ences which  have  been  supposed  to  give  rise  to  phthisis,  are  not 
after  all  proved  to  be  the  real  causes  of  its  production.  In  draw- 


PHTHISIS.  339 

ing  conclusions  in  medicine,  many  mistakes  are  made.  From  too 
limited  observation  of  a  few  phenomena,  varied  by  modifying  cir- 
cumstances, deductions  are  often  drawn,  in  which  there  is  neither 
truth  nor  reason.  One  very  prominent  cause  why  so  much  diver- 
sity of  opinion  prevails  in  relation  to  the  nature  and  treatment  of 
phthisis,  is  the  different  manner,  and  the  degrees  of  caution,  used 
by  physicians  in  making  their  investigations.  In  determining  the 
causes  of  phthisis,  the  same  difficulties  that  meet  the  philosopher 
in  arriving  at  any  definite  conclusions, — conclusions  the  truth  of 
which  can  be  demonstrated, — meet  also  the  physician.  We  should 
then,  when  examining  statistics  in  relation  to  the  causes  of  dis- 
ease, before  drawing  conclusions,  inquire  into  the  character  of  the 
circumstances,  under  which  the  statistics  were  made. 

Among  the.  causes  of  phthisis,  hereditary  predisposition  occu- 
pies tlie  most  important  place.  And  yet  this  hereditary  tendency 
explains  nothing  in  relation  to  the  real  cause  of  the  disease.  It  is 
the  name  of  a  fact  not  a  cause,  which  is  sure  to  produce  specific 
results.  We  must,  therefore,  in  order  to  arrive  at  anything  defi- 
nite or  practical,  seek  to  find  that  in  which  the  fact  has  its  origin 
— whether  it  be  a  peculiar  state  of  the  blood,  a  want  of  func- 
tional power, — in  the  digestive  organs,  or  in  the  respiratory  appar- 
atus. Vitality  is  the  effect  of  so  many  conditional  causes,  each 
liable  to  vary  in  intensity  and  thus  by  that  variation,  to  influence 
the  result, — the  degree  of  vitality, — that  it  is  difficult  to  tell  in 
what  ultimate  change  phthisis  has  its  origin.  But  the  nearer  we 
can  ascend  to  the  sources  of  knowledge,  the  more  general  and 
conditional  that  obtained  knowledge  becomes,  for  all  other  knowl- 
edge, related  to  it.  as  species  to  genera.  Accordingly  it  is  evi- 
dent, that,  if  chemistry  or  optics  could  detect  that  condition  of 
the  blood, — whatever  it  is — which  is  most  prevalent  in  the  pro- 
geny of  tuberculous  parents,  before  deposition  of  tuberculous 
matter  takes  place,  a  general  fact  would  be  obtained  of  more 
value  than  many  particulars  often  spoken  of  by  medical  writers. 
From  pathology  or  from  chemistry,  we  gain  no  evidence,  that 
'  those  who  are  predisposed  to  phthisis,  have  blood  differing  essen- 
tially from  that  of  others.  And  the  existence  of  the  hereditary 
tendency  has  been  questioned  by  some  recent  observers.  But  be- 
cause of  the  non-appearance  of  an  abnormal  change  in  the  con- 


340  THORACIC    DISEASES. 

stituents  of  the  blood,  except  in  rare  cases,  or  because  the  exist- 
ence of  that  tendency  is  denied,  we  should  not,  therefore,  con- 
clude that  hereditary  influence  does  not  exist.  It  may  exist,  bnt 
not  as  an  ultimate  cause,  ever  producing  a  certain  result. 

In  all  the  blood  probably  contains  the  elements  of  tubercle. 
Why  then  do  those  elements  leave  the  mass  of  the  blood,  and  lo- 
cate, as  foreign  or  heterogenous  matter,  upon  the  surfaces  of  mem- 
branes or  in  the  texture  of  organs?  And  why  does  this  effect 
take  place  more  frequently  in  the  children  of  phthisical  parents? 
To  answer  these  questions  according  to  science  will  require  a 
more  philosophic  spirit  than  mine.  And  yet,  to  me  it  seems  ra- 
tional to  suppose  that  the  constituents  of  the  blood  are  held  to- 
gether, by  an  affinity — be  it  chemical,  or  vital, — the  strength  of 
which  is  modified  in  degree  by  any  cause  which  can  debilitate 
the  system, — which  can  lessen  the  nutritive  properties  of  the 
blood.  Certain  constituents  of  the  blood,  by  that  affinity,  are 
held  together  by  a  stronger  force  than  others,  or,  certain  of  them, 
have  a  stronger  affinity  for  surrounding  elements  than  others. 
And  whenever  from  any  cause,  from  deficient  nutrition,  or  from 
impure  air,  this  affinity  is  lessened,  then  upon  the  surfaces  of 
those  membranes,  in  which  exosmose  is  easily  effected,  certain 
elements  of  the  blood, — those  having  a  strong  affinity  for  other 
textures,  not  being  at  all  within  the  control  of  vital  affinity, — are 
exuded.  The  second  question  it  seems  to  me,  involves  nothing 
more  than  this  general  principle  in  all  animal  life ; — the  tendency 
to  impart  to  the  progeny  the  attributes  of  the  parent.  As  is 
the  character  of  the  germ,  so  is  that  of  its  natural  completed  prod- 
uct. Hereditary  predisposition  seems  on  analysis,  to  resolve  it- 
self into  this  origin.  A  certain  train  of  causes,  acting  fora  long 
time  and  in  one  direction,  will  give  rise  in  those  not  predisposed 
to  phthisis,  to  tubercoulous  disease,  or  at  least  will  cause  a  condi- 
tion of  things,  approaching  to  that  which  will  give  rise  to  tuber- 
cles. A  parent  has  been  under  certain  influences,  but  they  may 
not  have  produced  in  his  system,  tuberculous  disease  in  its  devel- 
oped form.  This  same  condition  is  handed  down  to  the  pro- 
geny, and  then  the  same  causes  act  upon  the  latter  which  did 
upon  the  former.  But  in  the  latter,  at  the  beginning  of  life,  the 
condition  of  the  system  is  already  less  adverse  to  the  development 


PHTHISIS.  341 

of  phthisis  than  was  that  of  the  parent  at  the  beginning  of  his 
existence.  And  hence  the  acting  of  that  train  of  causes  upon  the 
child,  which,  in  the  parent  did  not  produce  phthisis,  but  which 
had  he  lived  long  enough,  would  have  done  so,  develops  phthisis 
in  the  child.  I  ask,  then,  if  we  seek  for  an  ultimate  cause,  to 
what  shall  we  attribute  the  beginning  of  the  predisposition? 
Does  it  not  spring  from  the  other  causes  of  phthisis  ?  and  is  it 
anything  more  than  a  continuation  of  the  effects  of  exciting 
causes  ?  If  not,  our  prophylactic  treatment,  in  order  to  strike  at 
the  root  of  the  tree,  should  be  directed  to  the  removal  of  those 
causes  which,  when  long  continued,  give  rise  to  any  disease 
whose  tendency  is  to  produce,  in  the  parent,  depression  of  the 
vital  forces,  and  thus  secondarily  to  beget  in  the  child  that  predis- 
position of  which  authors  speak.  There  is  some  variation  in  the 
statistics  of  different  authors,  concerning  the  number  of  phthisi- 
cal patients  in  a  given  number,  who  have  been  born  of  consump- 
tive parents.  Dr.  Swett,  deducing  his  conclusion  from  private 
practice,  thinks  that  seventy-five  in  a  hundred  of  phthisical  pa- 
tients, belong  to  consumptive  families. 

"  The  influence  of  age  in  the  production  of  phthisis  is  very 
remarkable.  A  large  proportion  of  those  affected,  die  between 
the  ages  of  twenty  and  thirty  years.  Dr.  Walshe  includes  forty- 
one  per  cent,  of  the  whole  number  between  these  periods.  Bri- 
quet states  that  three-fifths  of  those  who  suffer  from  the  disease 
are  attacked  between  the  ages  of  twenty  and  thirty-five  years. 
Children  are  by  no  means  exempt  from  its  ravages.  While  all 
admit  the  rarity  of  tuberculous  deposits  in  the  lungs  of  the  foetus, 
still  they  are  sometimes  noticed.  The  lungs  of  a  new-born  in- 
fant may  be  completely  studded  with  tubercles.  Although  the 
tendency  to  the  disease  rapidly  diminishes  after  the  age  of  thirty 
or  thirty-five  years,  yet  it  is  so'iietimes  met  with  even  in  advanced 
life. 

"  Sir  James  Clark  places  the  mortality,  between  the  ages  of  fifty 
and  sixty  years,  at  108,  as  compared  with  285,  representing  the 
mortality  between  the  ages  of  twenty  and  thirty  years.  My  own 
impression  is,  that  when  individuals  who  have  passed  the  middle 
period  of  life  are  attacked  with  phthisis,  the  disease  progresses 
less  rapidly  than  at  any  earlier  period  of  life,  and  that  many  thus 


342 


THORACIC    DISEASES. 


die,  after  having  suffered  from  the  disease  for  a  considerable  por- 
tion of  their  lives." — [Sicetfs  Lectures.] 

Occupations  of  Life. — Concerning  the  causes  of  phthisis, 
Lombard,  of  Geneva,  has  given  us  some  valuable  statistical  infor- 
mation. The  result  of  his  researches  is  thus  stated  : — "  The  cir- 
cumstances which  increase  the  tendency  to  phthisis  are  poverty, 
sedentary  habits,  violent  exercise  of  the  chest,  an  habitually  bent 
position  of  the  body,  impure  air  in  workshops,  the  inhalation  of 
certain  mineral  and  vegetable  vapors,  or  air  loaded-  with  a  coarse 
or  impalpable  dust,  or  with  light,  thready,  elastic  substances." 

"  The  circumstances  which  seem  to  exert  a  favorable,  preserva- 
tive influence,  are  easy  circumstances,  an  active.life  in  the  open 
air,  regular  general  exercise,  the  inhalation  of  watery  vapor,  and 
finally,  animal  and  vegetable  emanations." 

This  general  summary  of  the  results  of  extended  observation 
is  worthy  of  consideration.  The  influence  of  poverty  in  the  pro- 
duction of  phthisis  is  considerable.  But  the  attending  circum- 
stances, anxiety  of  mind,  exposure,  poor  food  and  deficient  cloth- 
ing, have  without  doubt  much  to  do  in  producing  the  result. 

The  proportion  of  deaths  from  phthisis  in  those  professions 
practiced  by  the  higher  classes  of  society  is,  according  to  Lom- 
bard, only  one-half  as  great  as  among  the  poorer  classes.  In  Ge- 
neva only  fifty  in  one  thousand  deaths  occur  from  phthisis  among 
those  living  on  their  incomes,  while  the  average  number  of  deaths 
among  all  classes  is  one  hundred  and  fourteen  in  one  thousand. 

Sedentary  habits  are  prone  to  produce  phthisis.  The  practice 
of  sitting  with  the  body  inclined  forward,  thus  preventing  the 
free  expansion  of  the  lungs,  and  the  action  of  the  stomach,  and 
other  abdominal  vircera,  is  one  cause  of  the  injurious  tendency  of 
a  studious  life.  Among  shoemakers,  and  tailors  the  proportion  of 
phthisical  patients  is  very  large. 

The  influence  of  the  inhalation  of  various  substances  is  a  sub- 
ject of  interest.  The  inhaled  substances  operate  in  two  ways : 
by  absorption,  and  by  the  mechanical  irritation  which  they  pro- 
duce. Of  the  former  class  are  gasses  and  vapors.  Of  the  latter, 
minute  particles  of  dust.  The  inhalation  of  the  mercurial  vapor 
tends  most  of  all  to  the  production  of  phthisis.  It  is  the  general 
opinion  of  physicians  that  mercurials  are  injurious  to  phthisical 


PHTHISIS.  343 

patients,  and  that  its  use  tends  to  produce  that  state  of  the  system 
favorable  to  the  development  of  phthisis.  Sir  James  Clark  says 
"  that  long  courses  of  mercury  on  the  constitution,  may  give  rise 
to  the  scrofulous  constitution." 

Those  exposed  to  the  vapor  of  lead,  and  other  mineral  agents 
are  not  particularly  liable  to  phthisis.  Among  those  who  inhale 
the  vapor  of  lead  the  number  of  deaths  from  phthisis,  in  one 
thousand  is  only  twenty-one,  while  among  those  who  inhale  that 
of  mercury  there  are  fifty-three  in  a  thousand. 

The  inhalation  of  dust  whether  animal,  vegetable  or  mineral, 
oftener  produces  a  fatal  form  of  chronic  bronchitis,  than  a  depo- 
sition of  tubercles.  M.  Lombard  jthinks,  that  mineral  dust  is  the 
most  injurious  of  all.  Those  agents  which  exert  the  most  injuri- 
ous influence  are  the  dust  arising  from  flints,  sandstone,  and  from 
steel;  and  hence  stone-masons,  miners,  coal-heavers,  brass  polish- 
ers and  metal  grinders  are  more  liable  casteris  paribus  than  others 
to  phthisis.  Among  animal  agents,  the  dust  arising  from  flax- 
dressing,  or  from  feathers  and  hair  is  most  injurious  ;  among  vege- 
table agents  the  dust  arising  from  the  dressing  of  cotton. 

Lombard's  opinion,  that  the  inhalation  of  \vatery  vapor  is  a 
preventive  of  phthisis,  should  be  somewhat  modified.  An  at- 
mosphere, warm  and  damp,  may  perhaps  have  a  beneficial  influ- 
ence in  phthisis.  But  in  our  country  in  which  moisture  and  cold 
are  often  combined,  such  a  result  is  seldom  found  to  be  true, 
but,  on  the  contrary,  the  moisture  and  cold  tend  to  produce 
phthisis.  All  along  the  Atlantic  coast,  those  cold  chilly  winds, 
accompanied  with  dampness,  are  among  the  most  powerful  causes 
of  consumption  incident  to  this  climate.  From  phthisis  M.  Lom- 
bard thinks  that  butchers,  tanners,  and  leather  dressers  are  re- 
markably exempt.  Of  late  it  has  been  asserted  that  those  whose 
occupation  tends  to  keep  the  surface  of  the  body  covered  with 
oily  matter,  are  not  so  liable  as  others  to  phthisis. 

According  to  the  observations  of  M.  Lombard  vegetable  emana- 
tions are  useful  to  prevent  tuberculous  disease.  "  But,"  observes 
Dr.  Swett  "the  truth  of  his  statement  may  well  be  doubted.  In 
certain  regions,  the  healthful  influence  of  vegetable  emanations 
may  be  true  enough.  But  if  the  various  forms  of  malarious  dis- 
ease, are  dependent  upon  this  cause,  then  we  must  class  these 


344  THORACIC    DISEASES. 

emanations  among  the  most  unfavorable  influences  in  the  produc- 
tion of  phthisis.  There  is,  indeed,  a  popular  opinion  in  this  coun- 
try, that  a  residence  in  a  malarious  region  is  favorable  to  phthisi- 
cal patients.  But  this  opinion  is  the  very  reverse  of  the  truth. 
Malarious  diseases  by  impairing  the  general  health,  favor  the 
development  of  phthisis,  and  much  increase  its  mortality." 

M.  Lombard,  from  his  investigations,  drew  the  conclusion,  that 
exercise  of  the  voice,  exerts  a  favorable  influence. 

Phthisis  is  usually  less  rapid  in  its  progress  in  feeble  constitu- 
tions than  in  those  more  vigorous.  Louis  is  of  the  opinion  that 
the  lymphatic  temperament  predisposes  to  phthisis.  But  it  is  evi- 
dent that  an  attempt  to  distinguish  the  different  temperaments 
could  not  lead  to  definite  conclusions. 

In  estimating  the  amount  of  influence  which  climate  exerts  in 
the  development  of  phthisis,  we  are  chiefly  dependent  upon  sta- 
tistics. Of  late  some  light  has  been  thrown  upon  this  subject  by 
the  valuable  reports  of  the  surgeons  of  the  British  army,  and  those 
of  the  late  Dr.  Torrey  of  the  United  States  army.  By  them  many 
erroneous  ideas  have  been  corrected.  Formerly  it  was  supposed 
that  phthisis  prevailed  almost  exclusively  in  temperate  latitudes, 
in  central  Europe,  in  the  northern  and  middle  parts  of  the  United 
States.  Accordingly  phthisical  patients  have  been  advised  to  re- 
move to  tropical  countries,  in  order  to  receive  protection. 

But  these  reports  prove  that  a  permanent  residence  in  tropical 
climates,  instead  of  preventing  the  development  of  phthisis,  tends 
rather  to  an  opposite  result.  There  is  a  difference,  however,  in 
the  unfavorable  tendency  of  tropical  regions,  on  the  same  parallels 
of  latitude.  The  West  Indies  are  more  favorable  to  the  produc- 
tion of  phthisis  than  the  East.  In  the  army  in  Great  Britain  the 
number  of  phthisical  patients  was  six  and  one  half  in  every  one 
thousand  men.  In  the  West  Indies,  in  Leeward  and  Windward 
Islands,  the  number  was  twelve  in  one  thousand ;  in  Jamaica, 
thirteen ;  in  the  Bermudas,  nine.  In  the  Mediterranean  the  aver- 
age number  of  phthisical  patients  is  six  in  one  thousand. 

The  climate  of  the  East  Indies  is  more  favorable  to  the  preven- 
tion of  phthisis  than  that  of  the  West.  Iti  Ceylon  and  along  the 
Bay  of  Bengal  it  is  seldom  known.  The  climate  of  Sweden  al- 
though cold,  is  more  favorable  to  the  prevention  of  phthisis  than 


PHTHISIS.  345 

that  of  England.     In  Canada,  too,  there  are  less  deaths  from  this 
disease  than  in  many  parts  of  the  United  States  and  England. 

"Contrary  to  general  belief,"  says  Dr.  Swett,  "consumption  is 
more  common  along  the  Atlantic  coast,  from  Delaware  Bay  to 
Savannah,  and  at  the  southwestern  ports,  than  at  the  northern 
Atlantic  ports,  and  at  those  situated  on  the  great  lakes.  While 
the  least  ratio  is  found  at  those  parts  in  the  northern  division  of 
the  United  States,  remote  from  the  ocean  and  the  lakes.  Thus, 
.so  far  as  our  own  country  is  concerned,  the  regions  least  predis- 
posing to  phthisis,  are  the  inland  states  in  the  northern  division, 
removed  equally  from  the  influence  of  the  ocean  and  of  the  great 
lakes." 

To  those  localities,  then,  we  should  send  consumptive  patients, 
rather  than  to  those  which  they  have  formerly  visited  for  the  im- 
provement of  their  health.  But  it  is  not  under  all  circumstances 
best  to  advise  a  removal  from  home,  in  order  to  obtain  the  benefit 
of  a  new  residence.  The  stage  of  the  disease,  during  which  such 
a  removal  will  prove  most  beneficial,  is  its  formative  one, — that 
stage  in  which  other  remedies  have  the  most  beneficial  effect. 

Malaria  is  a  poison  which  tends  to  undermine  the  constitution, 
and  to  lay  the  foundation  of  phthisis.  Phthisis  is  more  frequent 
in  malarious  regions.  To  this,  however,  there  are  exceptions. 
In  New  England  malaria  exerts  little  or  no  influence,  while  con- 
sumption is  very  prevalent. 

The  favorable  effect  of  a  sea-faring  life  is  generally  admitted, 
and  is  confirmed  by  good  evidence. 

Acute  Inflammations  of  the  Chest. — Inflammations  of  the  chest, 
such  as  bronchitis,  pneumonitis,  and  plcuritis,  have  been  supposed 
to  exert  an  unfavorable  influence.  The  two  former  diseases  I 
shall  in  the  first  place  consider.  Patients  often  trace  their  phthi- 
sical difficulties,  back  to  a  neglected  cold,  or  a  slight  attack  of 
bronchitis  or  pneumonitis,  and.  to  that  source  attribute  the  first 
cause  of  the  disease.  For  this  opinion  pathology  has  shown  that 
there  is  but  little  foundation.  Bronchitis  and  pneumonitis  attack 
the  lower  lobes  of  the  lungs,  or  the  larger  bronchial  tubes  which 
are  not  the  ordinary  seat  of  tuberculous  deposit.  Inflammation  is 
by  no  means  a  constant  attendant  upon  the  development  of  tuber- 
cles. 

44 


346  THORACIC    DISEASES. 

Pleuritis  is  sometimes  secondary  to  the  development  of  phthisis, 
and  sometimes  is  its  antecedent  and  exciting  cause.  It  is  much 
more  liable  to  be  so  than  either  bronchitis  or  pneumonitis.  Very 
often  \ve  meet  with  cases  in  which  the  phthisical  affection  seems 
to  immediately  follow  the  pleuritis.  We  may  safely  conclude, 
that  pleuritis  is  either  a  cause  of  the  development  of  phthisis  in 
those  who  would  not  have  had  the  disease,  were  it  not  for  the 
pleuritic  inflammation,  or  that  it  has  the  power  to  arouse  into  ac- 
tivity the  latent  form  of  consumption.  It  is  considered  mucli, 
more  favorable  to  the  development  of  tubercles,  than  the  inflam- 
matory diseases  of  the  air-passages,  and  parenchyma  of  the  lungs. 

Cseteris  paribus,  we  should  conclude,  that  if  inflammatory  af- 
fections of  the  thorax  were  causes  of  phthisis,  the  latter  disease 
would  be  most  frequent,  where  the  former  prevail  to  the  great- 
est extent.  There  should  be  on  this  supposition,  a  certain  ratio 
existing  between  the  prevalence  of  pneumonitis  and  bronchitis, 
and  that  of  phthisis.  But  it  is  not  so.  In  their  ratio  to  phthisis, 
they  differ  from  the  malarious  diseases.  According  to  Dr.  Forry's 
Reports,  where  phthisis  is  least  common,  there  bronchitis  is  most 
prevalent.  Nor  is  there  any  definite  relation  existing  between  the 
prevalence  of  pneumonitis  and  pleuritis,  and  that  of  phthisis. 

Is  phthisis  contagious?  Dr.  Watson  replies: — "No:  I  verily 
believe  it  is  not.  A  diathesis  is  not  communicable  from  person  to 
person.  Neither  can  the  disease  be  easily  generated  in  a  sound 
constitution.  Nor  is  it  ever  imparted  in  my  opinion,  even  by  one 
scrofulous  individual  to  another.  Yet  in  Italy  a  consumptive  pa- 
tient could  not  be  more  dreaded  and  shunned  if  he  had  the  plague. 
A  girl  dying  of  phthisis,  is  nursed  by  her  sister,  who  afterwards 
droops  and  dies  of  the  same  complaint.  Here  the  presence  of  the 
peculiar  diathesis  is  strongly  presumable.  But  the  parents  may  be 
different  in  blood.  A  wife  watches  the  death-bed  of  her  consump- 
tive husband,  and  presently  sinks  herself  under  consumption  ;  and 
there  may  be  no  traceable,  or  acknowledged  example  of  scrofula 
in  her  pedigree.  Yet  even  here  the  latent  diathesis  may  be  pre- 
sumed to  exist/'  Other  influences  aside  from  any  contagious  in- 
fluence hasten  on  the  development  of  the  disease.  These  are 
watching,  anxiety,  and  confinement  in  the  ill-ventilated  apartment 
of  the  sick-room.  The  effluvia,  arising  from  a  patient  in  consump- 


PHTHISIS.  347 

tion,  and  the  attendant  circumstances  should  be  considered  as  ex- 
citing causes,  the  influence  of  which  can  hasten  the  progress  of 
tuberculous  disease  in  others.  And  hence  sleeping  with  a  person 
laboring  under  phthisis,  especially  in  its  last  stage,  should  be  avoid- 
ed as  any  other  exciting  cause  of  consumption. 

Intemperance. — This  has  been  considered  a  cause  of  phthisis. 
Sir  James  Clark  remarks  : — "we  believe  that  the  abuse  of  spiritu- 
ous liquors  among  the  lower  classes  in  this  country  is  productive 
of  tuberculous  disease  to  an  extent  far  beyond  what  is  usually 
imagined.  Indeed,  it  is  only  necessary  to  observe  the  blanched 
cadaverous  aspect  of  the  spirit-drinker  to  be  assured  of  the  condi- 
tion of  his  internal  organs." 

This  tendency  of  intemperance  is.  however,  doubted  by  others 
in  the  profession,  whose  observations  are  extensive.  Of  35  per- 
sons dying  of  various  diseases,  all  of  whom  were  decidedly  in- 
temperate, and  most  of  them  grossly  so,  in  20,  according  to  Dr.  J. 
B.  S.  Jackson,  of  Boston,  [New  England  Quarterly  Journal  of 
Medicine  and  Surgery,  July,  1842,  p.  30,]  no  tubercles  were  found  ; 
in  5,  there  were  tubercles  in  the  lungs  ;  in  1,  in  the  bronchial 
glands ;  and  only  2  died  of  phthisis.  In  several  of  the  most 
striking,  the  organs  were  as  free  from  tuberculous  disease,  as  those 
of  a  new-born  infant.  These  results  led  Dr.  Jackson  to  suggest, 
whether  intemperance  may  not  have  some  effect  as  a  prophylactic? 
[Cyclopedia  Pract.  Mod.  Art.  Phthisis.] 

Dr.  Swctt  observes — "  Two  medical  gentlemen  attached  to  the 
public  dead-house  in  this  city, — New  York, — in  wThich  bodies  are 
deposited,  that  are  found  in  the  streets,  or  without  friends, — dis- 
covered in  about  scvent^  post-mortem  examinations  of  those  who 
died  of  the  most  confirmed  and  aggravated  intemperance,  not  a 
single  case  of  tuberculous  lungs.  A  most  surprising  result,  when 
we  remember  that  this  unfortunate  class  have  probably  long  suf- 
fered from  poverty,  bad  nourishment,  and  exposure  to  the  weather; 
influences  which  are  regarded  as  predisposing  to  tuberculous  de- 
posit. A  large  proportion  of  confirmed  drunkards  suffer  from 
hepatic  disease.  Is  a  tendency  to  hepatic  disease  antagonistic  to 
the  development  of  tubercles?"  Some  authors  think  so.  And 
yet  more  extended  observatipn  is  necessary  in  order  to  fully  sub- 
stantiate the  truth  of  such  a  conclusion..  The  modus  operandiof 


348  THORACIC    DISEASES. 

alcohol  in  acting  as  a  preventive,  is  not  as  yet  so  fully  understood 
as  could  be  desired.  And,  the  opinion,  that  it  really  is  benefi- 
cial in  the  prevention  and  cure  of  phthisis,  is  as  yet  deficient  in 
demonstrable  evidence.  And  yet,  on  analysis,  we  may  find  some 
ground  on  which  such  an  opinion  may  reasonably  be  founded. 
Those  means  which  act  as  revulsive  agents,  generally  arrest  the 
progress  of  those  diseases  to  which  they  are  opposed  in  their  ef- 
fects. Many  hygienic  means  operate  in  a  similar  way.  It  is  gen- 
erally admitted  that  certain  conditions  of  the  system  tend  to  arrest 
the  development  of  tubercles.  Among  these  are  pregnancy,  cer- 
tain chronic  bronchial  affections,  and  some  diseases  of  the  heart. 
Now  according  to  Rokitanshy,  all  these  conditions  tend  to  produce 
venosity  of  the  blood — an  effect  similar  to  that  produced  by  hepa- 
tic derangements. 

It  is  also  the  conclusion  of  Broide,  and  others,  that  alcoholic 
drinks  taken  into  the  stomach,  pass  by  absorption,  or  endosmose 
into  the  blood-vessels  and  with  the  blood  circulate  in  a  free  state. 
Liebig  asserts  that  alcohol,  when  circulating  with  the  blood, 
unites  with  its  oxygen,  and  forms  carbonic  acid  gas — thus  tending 
to  produce  a  venous  state  of  the  vital  fluid.  Bennet's  tes- 
timony is  in  accordance  with  that  of  Dr.  Jackson.  Dr.  Swett  re- 
marks, "that  tuberculous  cavities  are  more  frequently  found 
healed,  in  the  lungs  of  spirit  drinkers,  than  in  those  of  any  other 
class."  This  fact,  however,  is  far  from  being  absolute  proof  that 
the  alcoholic  stimulus,  is  alone  its  cause.  Some  other  stimulant 
in  an  anasmic  or  scrofulous  state  of  the  system  might  be  equally 
as  efficacious.  If  so,  we  should  by  all  means  use  the  substitute, 
and  not  entail  upon  the  patient  a  pernicious  habit  by  our  advice. 
Under  some  circumstances, — perhaps  in  asthenic  cases  of  phthisis 
— some  mild  alcoholic  beverage  combined  with  nourishing  food, 
is  very  useful.  By  its  use  in  this  manner  the  animal  tempera- 
ture is  elevated,  and  the  nutritive  functions  stimulated  to  increased 
activity.  Concerning  its  utility,  the  discriminating  practitioner 
can  learn  more  by  experimental  knowledge  than  by  theoretical. 

Dyspepsia. — In  dyspeptic  diseases,  many  authors  have  placed 
one  prominent  cause  of  phthisis.  And  well  it  is  that  they  have 
done  so.  For  since  tubercles  depend  for  their  development  upon 
a  want  of  nutrition  in  the  blood,  and  since  dyspeptic  diseases  de- 


PHTHISIS.  349 

prive  the  blood  of  its  nutritive   properties,  there  is  reason  to  be- 
lieve, that  in  this  source,  tubercles  may  have  their  origin. 

There  are  other  causes  of  phthisis  which  are  seldom  described 
in  medical  works.  Of  these,  one  is  masturbation  which,  by  its 
debilitating  effect  upon  the  general  constitution,  tends,  in  an  em- 
inent degree,  to  favor  the  development  of  tubercles.  Another 
cause  is  the  use  of  such  remedial  agents  in  the  cure  of  disease, 
as  leave  after  their  primary  effects  have  subsided,  secondary  ones, 
which,  in  the  end  prove  worse  than  the  original  disease.  One 
week's  sickness  treated  heroically,  often  lays  in  the  system  the 
foundation  of  chronic  complaints,  which  in  their  results  termin- 
ate only  with  the  end  of  life.  It  is  generally  admitted  that  mer- 
cury is  injurious  in  scrofulous  affections,  and  that  its  action  rather 
than  otherwise,  tends  to  develop  that  disease.  If  this  be  so, — 
and  the  history  of  thousands  of  invalids  corroborates  its  truth, — 
then  why  may  not  its  action  upon  the  system  directly  induce  tu- 
berculous disease?  Indirectly,  if  not  directly,  by  debilitating  the 
system,  by  destroying  the  red  blood,  by  inducing  emaciation,  it  so 
influences  the  mass  of  the  fluids,  as  to  leave  the  system  liable  to 
the  ingress  of  phthisis, — it  leaves  the  territory  unguarded  by  any 
vital  force — even  by  that  mysterious  one,  '•'  the  vis  mcdicatrix 
naturcc." 

A  patient  somewhat  predisposed  to  phthisis,  takes  a  severe  cold 
in  the  autumn.  Febrile  symptoms  supervene.  There  is  accord- 
ing to  the  opinion  of  some,  an  exalted  condition  of  vital  action  ; 
and  consequently  all  the  instruments  of  the  anti-phlogistic  regi- 
men and  treatment  are  immediately  used  to  subdue  the  inflamma- 
tion. After  a  number  of  weeks  the  patient  may  slowly  recover. 
But  his  digestive  organs  do  not  seem  to  be  healthy.  Strength 
does  not  return;  a  slight  cough  begins,  and  in  from  six  months  to 
a  year,  phthisical  symptoms  arc  fully  developed.  Such  cases  often 
occur,  and  so  often,  that  the  more  judicious  physicians  of  all 
creeds,  even  those  standing  on  the  conservative  platform,  now  be- 
gin to  abandon  the  use  of  dangerous  remedies,  not  because — as 
some  often  pretend — diseases  arc  now  so  different  in  their  nature 
as  not  to  require  the  same  treatment,  but  because  the  application 
of  science  to  the  study  of  medicine  has  exploded  the  idea,  that  it 
is  necessary  to  hazard  life,  by  the  use  of  deleterious  agents  in  or^ 
der  to  produce  a  speedy  and  complete  cure. 


350 


THORACIC    DISEASES. 


PROGNOSIS. — In  those  cases  in  which  the  disease  is  far  advanced, 
the  prognosis  is  always  very  unfavorable.  So  small  is  the  chance 
of  recovery,  that  the  physician  has  no  good  reason  to  encourage 
the  patient  or  the  friends.  But  morbid  anatomy  has  demonstrated 
that  even  in  the  last  stages  recoveries  do  take  place  ;  the  cavities 
are  filled  with  the  chalky  concretions,  their  parietes  contract  and 
cicatrices  are  produced.  What  else,  than  the  curability  of  phthi- 
sis do  such  facts  teach?  On  this  subject  Dr.  Swett  remarks,  "I 
never  shall  entirely  despair  of  the  life  of  a  patient  with  phthisis, 
when  I  recollect  what  I  once  witnessed  in  this  Hospital.  A  pa- 
tient was  admitted  with  phthisis.  The  disease  was  perfectly  well 
characterized,  and  in  its  most  advanced  stage ;  a  large  and  well 
marked  abscess  existed  under  the  right  clavicle.  Indeed,  the 
signs  of  this  lesion  were  so  distinct,  that  I  was  in  the  habit  of 
calling  the  attention  of  students  in  attendance  to  them  as  perfect 
in  their  characters.  On  one  occasion  as  I  approached  the  bed  for 
this  purpose,  I  found  the  patient  who  had  been  gradually  sink- 
ing, in  such  a  state,  that  it  seemed  to  me  improper  to  disturb  him. 
He  was  bolstered  up  in  bed,  with  his  head  falling  upon  his  shoul- 
der, breathing  with  great  difficulty,  bathed  in  perspiration,  and 
with  a  rapid  and  feeble  pulse.  The  next  day  my  attendance 
ceased,  and  after  two  months,  was  again  commenced.  On  enter- 
ing the  ward,  the  house  physician  called  my  attention  to  a  man, 
dressed,  walking  about  the  ward  apparently  stout  and  well,  al- 
though somewhat  pale.  To  my  great  astonishment  I  found  that 
it  was  the  very  case  of  phthisis  I  had  left  two  months  before  ap- 
parently dying."  The  same  author  testifies  that  he  has  known  a 
number  of  patients  who  have  had  all  the  evidences  of  phthisis, 
and  yet  have  recovered. 

In  such  cases,  however,  the  subsequent  health  is  not  so  good  as 
it  would  have  been  had  they  not  been  injured  by  the  phthisical 
lesions.  At  times,  a  little  cough  and  dyspnoea  continue,  but  the 
patient  is  able  to  attend  to  ordinary  business.  The  number  of 
those  whose  lungs  evince,  after  death,  indications  of  the  effect  of 
the  curative  process,  is  much  greater  than  has  been  supposed. 
Indeed,  it  is  not  uncommon  to  find  in  the  lungs  of  those  who 
die  of  almost  every  form  of  chronic  disease,  chalky  concretions, 
ancient  traces  of  tuberculous  disease.  A  French  physician  found 


PHTHISIS.  351 

in  one  hundred  women,  all  above  sixty  years  of  age,  and  dying 
of  various  diseases,  fifty-one  who  presented  the  curative  indica- 
tions of  tuberculous  disease,  and  chiefly  by  the  formation  of 
chalky  concretions.  To  such  testimony,  the  common  reply  is, 
that  they  were  not  after  all,  cases  of  phthisis.  If  so,  and  if  no 
case  ever  did  recover  after  cavities  were  fully  formed,  how  I  ask 
does  it  happen  that  the  lungs  in  so  many  cases  show  the  indica- 
tions of  cured  phthisis?  No  one  who  has  any  knowledge  of  tu- 
bercular consumption  will  affirm,  that  it  is  not  always  a  formida- 
ble disease,  that  its  prognosis  is  not  always  unfavorable.  But  it 
is  not,  therefore,  the  part  of  reason,  to  deny  facts,  plainly  testify- 
ing that  the  disease,  under  favorable  circumstances,  and  especially 
when  early  treated  by  the  most  appropriate  human  means,  does 
occasionally  terminate  favorably.  Dr.  Wood  of  Philadelphia, 
mentions  two  instances  of  this  kind  in  medical  men  of  that  city. 
One  of  the  patients  was  affected,  when  a  young  man,  with  all  the 
symptoms  of  phthisis,  including  frequent  attacks  of  haemoptysis, 
severe  cough,  hectic  fever,  &c.,  from  which  he  completely  recov- 
ered, and  continued  exempt  up  to  the  time  of  his  death,  which 
occurred  many  years  afterward  of  typhoid  fever.  [See  N.  Am. 
Mod.  and  Surg.  Journal,  viii.  277.]  The  second  case  was  the 
late  Dr.  Joseph  Parrish,  who  in  early  life  had  phthisis,  and  recov- 
ered. At  an  advanced  age  he  died,  and  cicatrices  were  found  in 
the  upper  part  of  one  lung. 

V 

SECTION  VI. 
TREATMENT. 

The  indications  in  the  treatment  of  phthisis  are  first,  to  pre- 
vent the  further  deposition  and  development  of  tubercles,  and, 
secondly,  to  protect,  as  far  as  possible,  the  lungs  and  other 
organs  from  their  injurious  results. 

1.  To  prevent  the  development  and  deposition  of  tubercles. — 
The  means  both  prophylactic  and  remedial,  which  can  be  of  any 
utility  for  this  purpose,  must  be  directed  to  the  attainment  of  this 
result] — the  production  of  that  state  of  the  solids  and  fluids  which 
is  most  adverse  to  the  development  of  tubercley.  The  primary 


35'2  THORACIC    DISEASES. 

pathological  changes  in  phthisis,  are  few  and  simple.  And  so 
they  remain  until  the  sequences  of  the  repulsive  powers  of  the 
system,  produce  lesions  of  textures,  more  difficult  to  be  removed, 
than  even  the  primary  changes.  The  remedies  which  alter  the 
primary  state  of  the  tissues,  are  also  of  a  simple  character,  and 
only  a  few  are  required,  when  seasonably  and  properly  applied. 
These  agencies  must  excite  absorption  and  secretion. 

A  diminution  of  the  nutritive  properties  of  the  blood  in  phthi- 
sis, is  now  a  well  established  fact.  In  order  to  remove  this  con- 
dition, we  must  therefore  direct  our  remedial  and  hygienic  means 
to  those  sources,  whose  condition  determines  the  character  of  the 
blood. 

The  air  is  one  source — the  chyle  the  other.  Whatever  tends 
to  keep  these  sources  of  life  pure,  must  tend  to  keep  pure  their 
product,  the  blood.  Pure  air  then  is  indispensible  to  the  preven- 
tion and  cure  of  phthisis.  And  since  exercise  in  the  open  air,  in- 
creases respiration,  thereby  tending  to  expose  the  blood  to  the  ac- 
tion of  atmospheric  elements,  it  becomes  a  potent  means  of  pre- 
venting the  progress  of  tubercles. 

To  be  effective,  this  must  be  long  continued.  A  short  walk 
now  and  then  is  not  sufficient.  It  must  be  persevered  in,  in  order 
to  have  any  permanent  effect.  At  first  it  should  be  gentle,  and 
not  continued  until  exhaustion  is  produced.  Its  increase  should 
be  in  proportion  to  the  increase  of  strength.  The  state  of  the 
weather,  should  not  often  be  considered  an  insurmountable  obsta- 
cle. Let  the  clothing  be  adapted  to  the  circumstances,  and  proper 
care  be  taken  after  exercise,  not  to  take  cold  by  exposure  to  cur- 
rents of  cold  air,  or  by  too  quickly  taking  off  the  clothing,  and 
there  need  be  no  fear  as  to  the  result.  There  is  prevalent  in  the 
community  a  great  error,  in  regard  to  the  prevention  of  catarrh 
by  close  confinement.  Close  confinement,  instead  of  being  a 
preventive,  is  an  actual  cause  of  catarrh,  and  many  other  pulmon- 
ary difficulties.  Experience  fully  confirms  this  opinion.  Those 
who  are  most  sedentary  in  their  habits,  the  least  exposed  to  the 
vicissitudes  of  the  weather,  are  casteris  paribus,  most  liable  to  pul- 
monary consumption.  These  remarks  as  to  exercise,  of  course, 
apply  to  the  early  stage  of  phthisis,  when  there  is  no  great  de- 
bility. 


PHTHISIS.  353 

The  character  and  degree  of  exercise  must  depend  upon  cir- 
cumstances. Severe  exercise  has  in  some  cases  proved  beneficial, 
by  arousing  to  activity  the  vessels  of  the  minutest  tissues.  By 
this,  sudden  changes  in  the  secreting  and  excreting  vessels  have 
been  effected.  Dr.  Salvador!  directed  his  patients  in  the  morning 
to  climb,  as  quickly  as  they  could,  some  eminence,  till  they  were 
out  of  breath,  and  bathed  in  sweat ;  and  then  to  place  themselves 
near  a  large  lire  to  increase  the  perspiration.  Afterwards  they 
were  directed  to  change  their  linen,  and  gradually  withdrawing 
from  the  fire,  to  partake  freely  of  salted  meat  and  wine. 

Dr.  Parrish,  who,  having  no  faith  in  the  treatment  of  the  pro- 
fession in  this  disease,  threw  all  their  remedies  aside,  and  followed 
the  advice  of  Sydenham, — makes  the  following  remarks  : — "Vig- 
orous exercise  and  free  exposure  to  the  air,  are  by  far  the  most  ef- 
ficient remedies  in  pulmonary  consumption.  It  is  not,  however, 
that  kind  of  exercise  usually  prescribed  for  invalids — an  occasion- 
al walk  or  ride  in  pleasant  weather,  and  strict  confinement  in  the 
intervals — from  which  much  good  is  to  be  expected.  Daily  and 
long-continued  riding  on  horse-back,  or  in  carriages  over  rough 
roads,  is,  perhaps,  the  best  mode  of  exercise  ;  but,  where  this  can- 
not be  commanded,  unremitting  exertion  of  almost  any  kind  in 
the  open  air,  amounting  even  to'  labor,  will  be  found  beneficial. 
Nor  should  the  weather  be  scrupulously  studied.  Though  I 
would  not  advise  a  consumptive  patient  to  expose  himself  reck- 
lessly to  the  severest  inclemencies  of  the  weather,  I  would,  nev- 
ertheless, warn  him  against  allowing  the  dread  of  taking  cold  to 
confine  him,  on  every  occasion,  when  the  temperature  may  be 
low  or  the  skies  overcast.  I  may  be  told,  that  the  patient  is  often 
too  feeble  to  bear  the  exertion  ;  but,  except  in  the  last  stage,  when 
every  remedy  must  prove  unavailing,  I  believe  there  are  few  who 
cannot  use  exercise  out  of  doors;  and  it  sometimes  happens  that 
they  who  arc  exceedingly  debilitated,  find  upon  making  the  trial, 
that  their  strength  is  increased  by  the  effort,  and  that  the  more 
they  exert  themselves,  the  better  able  they  are  to  support  the 
exertion." 

The  temperature  of  the  body  should  be  equal,  not  exposed  by 
a  want  of  clothing,  or  sudden  changes  of  heat  and  cold.     The 
clothing,  therefore,  should  be  such  as  not  to  permit  the  body  to  be 
45 


354  THORACIC    DISEASES. 

suddenly  chilled.  Flannels,  and  woolen  clothes  generally  are  best 
adapted  to  sustain  an  equilibrium  in  the  heat  of  the  system,  and 
thus  to  keep  up  an  equal  circulation  of  the  blood.  The  influence 
of  climate,  in  accomplishing  this  indication,  is  often  considerable. 
The  mild  winters  of  some  tropical  regions,  in  two  respects,  are 
beneficial  to  a  phthisical  patient.  First,  they  tend  to  promote, 
more  than  a  cold,  changeable  climate,  the  cutaneous  capillary  cir- 
culation, and  secretion,  and  also,  in  the  second  place,  afford  to  the 
patient  better  facilities  for  exercise  in  the  open  air.  "  In  choos- 
ing a  place  of  residence,"  says  Dr.  Wood,  "  preference  should  be 
given  to  those  situations  which  are  at  the  same  time  dry  and  of  a 
uniform  temperature." 

In  Madeira,  the  climate  is  very  favorable  to  the  cure  of  phthi- 
sis. It  is  perhaps  least  prevalent  in  Ceylon  and  along  .the  shores 
of  the  Bay  of  Bengal.  But  the  increased  liability  existing  in 
those  localities  to  hepatic  and  abdominal  diseases,  makes  a  resi- 
dence there,  dangerous. 

In  the  West  Indies,  Santa  Cruz  is  perhaps  the  best  place  :  and 
the  accommodations  there  derivable  are 'good.  In  our  country 
the  interior  of  Florida,  is  thought  by  Dr.  Swett,  to  be  the  best 
place  for  a  consumptive  patient.  He  recommends,  the  patient  at 
the  approach  of  Spring,  or  as  soon  as  the  heat  becomes  a  little 
oppressive,  to  move  a  little  northward,  keeping  back  from  the  sea 
coast.  To  spend  a  month  or  two  at  Aiken,  in  South  Carolina, 
to  reach  Richmond,  Virginia,  about  the  beginning  of  May.  and  to 
return  to  the  Northern  States  about  the  tenth  of  June.  He,  also, 
recommends  patients  to  go  South  sometime  in  October  or  early  in 
November.  In  some  cases, — in  those  who  bear  well  the  cold  of 
autumn, — he  thinks  that  they  may  stay  North  until  December  or 
even  January. 

What  kind  of  patients  most  frequently  receive  benefit  from  a 
change  of  climate?  They  are,  in  general,  those  in  whom  the 
disease  has  not  far  advanced,  in  whom  there  is  no  hereditary  pre- 
disposition, but,  on  the  contrary  a  strong  tendency  to  health,  a 
strong  constitution.  Those  in  whom  the  phthisical  affection  is 
not  complicated  with  any  other  disease,  in  whom  its  progress  is 
slow,  located  on  one  lung  only,  and  confined  to  a  small  portion, 
showing  a  strong  tendency  to  pause  in  its  development. 


PHTHISIS.  355 

The  regulation  of  diet  is  also  an  important  part  in  the  treatment 
of  phthisis.  This  should  consist  of  those  articles  which,  while 
they  arc  easily  digested,  afford  a  rich  supply  of  nutriment  to  the 
blood. — enough  to  combine  with  the  oxygen  of  the  air  and  pro- 
duce that  condition  of  the  circulating  fluid  most  adverse  to  the 
development  of  tubercles.  Among  the  more  nutritious  articles 
allowable  in  the  first  stage,  are  beef,  eggs,  oysters,  mutton;  among 
those  less  nutritious,  are  milk,  fish,  farinaceous  articles  and  diges- 
tible fruits. 

The  greater  the  amount  of  exercise,  the  more  nutritious  should 
be  the  diet.  Moderately  stimulating  drinks,  such  as  porter,  ale, 
and  pure  wine,  are  often  very  useful.  To  the  ust;  of  any  alco- 
holic beverage  in  this  stage,  some  object;  saying  that  it  tends  to 
produce  inflammatory  action.  This  may  be  so  to  some  extent. 
But  it  should  be  recollected,  that  phthisis  is  in  an  eminent  degree 
a  disease  of  debility,  and  its  attendant,  fever, — especially  in  the 
first  stage,  is  of  an  irritative  character,  arising,  not  from  phlogosis, 
but  from  anaemia,  or  from  defective  nutrition.  It  is  the  opinion 
of  Prof.  William  Tully,  that  pure  natural  wine, — the  venous  prin- 
ciple independent  of  the  water  and  other  substances  with  which 
it  is  mixed, — is  digestible  to  a  limited  extent,  and  affords  to  the 
system  a  small  amount  of  nutriment.  (Tally's  Materia  Medica, 
V61  I,  No.  1,  p.  4.) 

Mental  influences  are  frequently  important  therapeutical  agents 
in  this  disease.  Disappointment,  anxiety,  and  grief  produce  a 
depressing  influence,  directly  tending  to  arrest  digestion,  and  thus 
deprive  the  blood  of  its  normal  amount  of  chyle.  Intense  study, 
or  any  sedentary  business  which  occupies  the  attention  too  con- 
stantly, should  be  avoided.  Hope  should  be  encouraged.  The 
patient  should  not  be  told  by  every  friend  whom  he  may  chance 
to  meet,  that  his  case  is  consumptive.  Let  his  mind  be  diverted, 
by  amusing  incidents,  and  by  a  variety  of  pleasing  and  interest- 
ing novelties.  To  this  diversion  of  the  mind,  traveling  owes 
much  of  its  utility  as  a  remedial  agent.  Short  sea  voyages  may 
be  useful  for  this  purpose. 

Medicines  in  this  disease  are  extremely  limited  in  their  influ- 
ence. Sometimes,  when  judiciously  prescribed,  and  when  the 
best  possible  selection  is  made,  they  arrest  the  progress  of  the 


356  THORACIC    DISEASES. 

disease,  or  at  least,  when  combined  with  proper  hygienic  means, 
they  render  a  cure  more  probable  than  it  otherwise  would  be. 
But  every  agent  which  tends,  either  primarily  or  secondarily  to 
produce  debility, — such  as  those  comprised  in  the  antiphlogistic 
regimen, — powerful  cathartics,  diaphoretics,  in  short  all  general 
evacuents,  are  in  my  opinion  contra-indicated,  and,  therefore,  their 
use  should  be  entirely  abandoned  except  in  cases  complicated 
with  other  diseases. 

Among  many  practitioners  of  experience,  the  practice  of  ad- 
ministering frequent  emetics,  has  been  prevalent.  There  is  un- 
questionably a  period  in  which  these,  when  properly  given,  have 
a  beneficial  effect.  That  period  is  in  the  incipient  stage,  when 
tuberculous  matter  is  not  softening,  and  when  the.  capillary  circu- 
lation, and  the  digestive  functions  are  first  deranged.  My  opinion 
is,  that,  in  incipient  phthisis  emetics  are  serviceable,  chiefly 
through  their  power  of  exciting  capillary  action,  and  of  diverting 
from  the  pulmonary  tissues,  all  morbid  matter.  With  them  it  is 
necessary  to  use  the  hot  air  or  vapor  bath,  followed  by  long  con- 
tinued frictions,  and  by  strong  tonics,  and  nourishing  food.  One 
prominent  cause  of  failure,  in  this  as  in  other  courses  of  treatment, 
is  this : — the  patient  is  prone  to  think,  that  the  medicine  will  do 
the  cure  without  exercise,  and  the  adoption  of  other  hygienic 
means.  It  would  be  well  for  the  consumptive,  if  physicians, 
while  regulating  the  kind  and  administration  of  medicine,  would 
pursue  a  course  with  the  patient,  similar  to  that  adopted  in  hydro- 
pathic establishments, — a  course  of  exercise,  and  rigid  physical 
discipline. 

When  such  complications  exist  as  to  make  emetics,  cathartics, 
or  other  evacuant  remedies  necessary,  they  may  be  given.  In 
febrile  phthisis,  diaphoresis  should  be  promoted,  and  the  stomach, 
if  in  a  morbid  state,  cleansed  by  an  emetic.  Other  organs  should 
receive  such  attention  as  their  pathological  condition  may  seem  to 
indicate.  The  efficacy  of  repeated  emetics  in  all  cases,  or  even 
in  a  majority  of  cases  of  phthisis,  I  very  much  doubt.  When 
the  stomach  is  not  particularly  dyspeptic,  they,  after  softening  has 
commenced,  seem  to  me  decidedly  injurious ;  in  the  first  place, 
they  tend  to  increase  the  bronchial  secretion  which,  diluting  the 
tubercular  masses  in  the  minute  ramifications  of  the  bronchi, 


PHTHISIS.  357 

produces  a  tendency  to  the  softening  of  tubercles.  And  secondly, 
they  debilitate  the  system,  by  the  relaxation  which  they  occasion, 
and  by  the  prolonged  diaphoresis  which  they  induce.  I  very 
well  know  that  they  often  relieve  the  dyspnoea,  and  many  times 
other  rational  symptoms.  But  this  is  merely  the  primary  or  pal- 
liative effect ;  the  secondary,  is  the  production  of  debility.  Phthi- 
sis demands  the  use  of  revulsive  means, — means  which  determine 
away  from  the  lungs,  all  matter  that  may  seek  an  exit  from  the 
system  through  the  bronchial  membrane,  but  those  means  should 
not  tend  to  produce  debility, — the  bad  effect  of  emetics.  Consump- 
tion, consequent  upon  the  recession  of  some  exanthematous  erup- 
tion, demands,  in  a  special  manner,  the  use  of  such  agents  as 
tend  to  throw  upon  the  surface  morbid  matter.  But  this  revulsive 
eifect  must  be  produced,  if  produced  at  all,  not  by  such  cutane- 
ous evacuants  as  act  at  the  expense  of  the  strength  of  the  patient, 
but  by  those  which  call  to  the  surface  the  full  and  normal  quan- 
tity of  blood,  and  do  this  too,  without  producing  debility.  How 
can  this  be  done  ?  My  method  is  to  place  the  patient  over  the 
vapor  of  water  and  alcohol,  until  the  superficial  veins  are  full, 
and  a  warm  glow  is  felt  over  the  entire  body.  I  then  apply  with 
a  sponge,  either  tepid  or  cold  water,  according  to  the  reacting 
power  in  the  system,  and  follow  by  continued  and  brisk  friction. 

There  is  no  need — and  indeed  it  is  decidedly  injurious,  to 
continue  the  bath  until  relaxation  follows.  The  tonic,  stimulat- 
ing and  cleansing  effect  is  all  we  want.  This,  in  the  early  stage, 
should  be  frequently  repeated,  especially,  if  the  circulation  is  fee- 
ble, in  the  extremities.  In  most  cases  this  remedial  agent  causes 
the  pulse  to  diminish  in  frequency,  but  to  increase  in  volume,  in 
short,  it  changes  for  awhile  the  small  jerking  pulse  of  irritative 
fever,  to  the  more  full,  slower  pulse  of  health.  For  stimulating 
the  surface,  after  the  bath,  mustard  water  is  often  highly  service- 
able in  cases  of  debility. 

Dr.  Gallup,  speaking  of  the  efficacy  of  the  universal  warm 
bath  in  phthisis  fully  corroborates  the  utility  of  this  mode  of  ap- 
plying caloric  to  the  system.  "  In  nine  cases  out  of  ten,"  he  ob- 
serves, "the  disease  is  excited  by  cold,  and  the  first  treatment 
requires  the  application  of  caloric  in  some  form  to  the  surface. 
Capillary  action  should  be  excited  on  the  surface  by  caloric,  by 


358  THORACIC    DISEASES. 

frictions  and  by  such  exercise  as  the  patient  can  bear.  Of  the 
utility  in  phthisis  of  the  warm  bath  I  am  fully  convinced.  I 
think  it  indispensible  in  recent  cases,  and  enjoin  it  every,  or  every 
other  evening,  before  retiring  to  bed.  It  may  be  continued  a 
month  or  two,  and  occasionally  for  a  much  longer  time,  if  there 
should  be  chilliness,  or  dryness  of.  the  skin.  It  even  moderates 
the  hectic  paroxysms,  and  converts  the  colliqnitive  sweats  into 
a  warm  perspiration.  A  temperature  of  about  100°  Fahrenheit 
may  be  employed,  but  always  such  as  to  be  agreeable,  and  easily 
borne  by  the  patient.  Sometimes  the  bath  may  be  impregnated 
with  chloride  of  sodium.  The  warmth  on  the  surface  should  be 
sustained  by  occasional  rubbings  with  warm  flannel,  by  a  suffi- 
ciency of  clothing,  with  flannel  next  the  skin  and  some  agreea- 
ble nutriment  mostly  in  a  fluid  form." 

For  internal  remedies  at  this  stage  I  use  preparations  of  iron, 
the  carbonate,  prussiate,  or  iodide,  according  to  the  indications. 
The  sirup  of  the  iodide  of  iron  mixed  in  an  alterative  sirup,  con- 
taining a  considerable  quantity  of  sugar,  is  a  very  excellent  com- 
pound. It  may  be  prepared  and  administered  as  directed  in  the 
article  on  pleuritis. 

The  wild-cherry  bark,  the  primus  virginiana,  is  highly  recom- 
mended as  a  tonic  to  the  digestive  and  nutritive  functions,  and  as 
a  sedative  to  the  nervous  system.  A  very  convenient  form  of 
administering  this  remedy  is  in  the  form  of  the  officinal  infusion, 
which  may  be  given  in  the  dose  of  a  large  wine-glassful,  two, 
three,  or  four  times  a  day,  and  continued  for  a  long  time  in  case 
the  remedy  seems  to  be  adapted  to  the  exigencies  of  the  case. 
Should  this  become  offensive  pipsisscwa,  or  simple  bitter  tonics 
may  be  used  with  benefit.  Among  these  are  salicin,  hydrastin, 
quinine,  columbo,  quassia  and  gentian  and  ginseng.  When  the 
pulse  is  very  frequent,  to  either  or  all  of  these  tonics  a  suitable 
quantity  of  hydrocyanic  acid  may  be  added  in  order  to  lessen  the 
rapidity  of  the  pulse,  and  allay  the  irritability  of  the  system. 
Tonic  and  alterative  compounds  should  be  composed  of  those  arti- 
cles which  seem  best  adapted  to  the  removal  of  the  symptoms. 
The  following  is  very  useful  : — 


PHTHISIS.  359 

J?t         Rumicis 

Stillingioe 

Inulao  hclenii 

Xanthoxyli 

Pruni  virginianae 

Solani  dulcamarse  a  a          §  j., 

Aquae  pluvial  is  Oij., 

Bulliant.  Decanta. 

Adde 

Sacch.  alb  §  iv., 

Potassa)  hydriodatis  §  ss.. 

Spirit!  vini  q.  s. 

Dose — one  table-spoonful  three  times  per  day. 

"  The  remedy  which  has  of  late  had  the  greatest  reputation  as 
a  curative  agent  in  this  disease,  is  the  cod-liver  oil, — oleum  jeco- 
ris  aselli.  This  oil  is  brought  to  market  in  three  principal  varie- 
ties ;  the  best  and  most  tasteless  is  nearly  or  perfectly  transparent, 
with  but  a  slight  odor  or  taste,  and  is  almost  always  taken  by 
patients  without  much  difficulty." 

"The  dose  of  the  cod-liver  oil,  is  a  table-spoonful  three  times 
a  day,  taken  in  a  little  of  the  froth  of  beer  or  porter;  any  other 
liquid  not  possessing  any  positively  medicinal  properties  may, 
however,  be  used  in  place  of  the  froth  of  malt  liquors.  A  very 
good,  and  perhaps  a  better  mode  of  taking  the  oil,  is  to  chew  a 
small  piece  of  orange  peel,  then  to  swallow  the  oil,  either  pure  or 
floating  in  some  aromatic  infusion,  or  a  little  rose  or  orange-flower 
water,  and  afterwards  again  to  chew  a  fragment  of  the  orange 
peel. 

"  Many  persons  are  not  able  to  take  the  oil  three  times  a  day 
without  repugnance  ;  it  may,  however,  often  be  given  to  them 
twice  a  day  without,  difficulty.  In  these  cases  it  should  be  given 
about  eleven  or  twelve  o'clock  in  the  morning  and  again  in  the 
evening.  It  is  in  general  best  to  begin  with  a  less  dose  than  a 
table-spoonful,  and  as  soon  as  the  patient  becomes  a  little  accus- 
tomed to  the  remedy,  it  should  be  increased  to  the  usual  dose. 
The  doses  should  not  be  so  large  as  to  excite  purging.  Some 
consumptive  patients  are  not  able  to  take  the  cod-liver  oil ;  in 


360  THORACIC    DISEASES. 

some  it  produces  much  nausea  and  an  insufferable  disgust.  This, 
however,  sometimes  subsides,  and  the  patient  acquires,  by  chang- 
ing the  manner  or  vehicle  of  administration,  the  power  of  retain- 
ing the  medicine  on  the  stomach.  Diarrhoea  contra-indicates  the 
use  of  the  oil,  especially  when  it  cannot  be  arrested  by  a  few 
drops  of  laudanum." 

"  When  the  cod-liver  oil  does  good  the  patient  increases  in 
flesh,  and  loses,  to  a  certain  extent,  the  characteristic  physiognomy 
of  phthisis.  The  pain  and  cough  also,  diminish — sometimes  are 
scarcely  to  be  perceived  at  all — while  the  physical  signs  of  the 
disease  are  also  sometimes  lessened,  although  generally  not  in 
proportion  to  the  decline  in  the  general  symptoms.  But  in  one 
patient  who  entered  the  Pennsylvania  Hospital  last  autumn,  under 
my  charge,  there  were  decided  crackling,  imperfect  cavernous 
respiration,  and  dullness  on  percussion  at  the  summit  of  one  of 
the  lungs,  together  with  fever,  cough,  and  emaciation.  He  was 
put  under  the  influence  of  the  oil  ;  at  first  the  only  kind  tried 
was  the  dark  colored  ;  this,  however,  produced  nausea  and  could 
not  be  taken  regularly ;  the  white  oil  was  afterward  given ;  the 
remedy  was  continued  by  Dr.  Wood,  during  his  term  of  duty. 
In  March,  1850,  about  six  months  after  he  had  commenced  the 
treatment,  he  had  become  much  fatter,  so  as  to  present  the  ap- 
pearance of  a  person  in,  at  least,  the  average  condition  of  health  ; 
the  pain  had  subsided  ;  the  cough  was  nearly  gone ;  and  the 
physical  signs  much  improved.  This  was  the  only  case  of  those 
treated  during  my  term  of  service  or  that  of  Dr.  Wood,  in  which 
the  amelioration  was  so  decided  as  to  merit  the  title  of  cure." 
[Dr.  Gerhard.] 

So  far  as  I  have  used  this  remedy,  I  have  reason  to  conclude, 
that  in  some  cases,  it  produces  a  decided  improvement  in  the 
strength  of  the  patient,  changing  the  expression  of  the  counten- 
ance, and  removing  many  of  the  general  and  rational  symptoms. 
Undoubtedly  its  value  as  a  curative  agent  has  been  overrated. 
This,  indeed,  is  almost  always  the  case  with  every  new  remedy. 
But  after  the  excitement  has  past  away,  and  the  calm  of  reason 
returns,  we  can  judge  better  as  to  its  real  merits.  In  one  case  of 
incipient  phthisis  which  1  treated  with  this  remedy,  I  am  satisfied 
that  it  produced  such  a  radical  change  in  the  system  as  to  at  least 


PHTHISIS.  361 

give  the  appearance  of  a  cure.  There  can  be  no  doubt  as  to  the 
phthisical  state  of  the  patient  before  the  remedy  was  prescribed. 
Belonging  to  a  family  in  which  the  scrofulous  diathesis  prevails, 
having  severe  cough,  dyspnoea,  and  the  physical  signs,  a  number 
of  physicians,  among  whom  was  Prof.  Newton,  considered  the 
symptoms  as  clearly  indicative  of  phthisis.  The  paler  variety  of 
the  oil  was  used  several  months.  The  amendment  was  gradual 
and  permanent.  The  person  now,  after  four  years,  is  as  free 
from  phthisical  symptoms  as  before  the  attack.  Such  favorable 
effects,  however,  are  rarely  witnessed.  In  the  majority  of  cases 
in  which  the  remedy  is  used,  the  amendment  is  but  temporary, 
and  the  patient  sinks  under  the  influence  of  the  disease.  Its 
utility  is  probably  greatest  as  a  preventive,  or  as  a  remedy  tc  re- 
move that  hereditary  tendency  to  phthisis,  sometimes  manifested 
by  a  voracious  appetite,  existing  coetaneously  with  emaciation. 
When  the  disease  progresses  slowly,  the  patient  gradually  losing 
flesh,  having  at  the  same  time  slight  cough,  and  alteration  of  the 
sounds  of  respiration  at  the  summit  of  one  of  the  lungs,  we  may 
sometimes  succeed  in  eradicating  the  disease. 

If  this  be  so,  cannot  this  remedy  cure  consumption  in  its  ad- 
vanced stage  ?  The  answer  must  depend  upon  what  we  mean 
by  a  cure.  If  it  be  this,  that  by  the  use  of  the  remedy  when 
the  system  is  in  the  most  favorable  condition  for  the  deposit  of 
calcareous  matter,  we  can  so  aid  the  reparative  process,  as  to  effect 
cicatrization,  when  without  the  remedy  the  case  would  have  ter- 
minated fatally,  then  I  think  we  can  safely  say  that,  sometimes, 
it  may  cure,  even  in  the  latter  stages.  But  we  never  can  know 
how  much  of  the  effect  is  due  to  nature,  and  how  much  to  the 
influence  of  the  remedy.  All  we  can  say  is  this: — that  the  use 
of  this  remedy,  when  it  can  be  tolerated,  places  the  system  in  a 
condition  more  favorable  to  restoration  than  it  would  be  without 
it. 

We  may  safely  conclude  that  this  remedy  has  no  specific  influ- 
ence in  phthisis,  and  that  its  modus  operand!  is  similar  to  that  of 
good  nourishment.  Other  kinds  of  oil  probably  would  have  sim- 
ilar effects.  But  on  account  of  this  we  should  not  deprive  our 
patients  of  all  the  benefit,  whether  it  be  as  nourishment,  or  as 
medicine,  derivable  from  its  administration. 
46 


362  THORACIC    DISEASES. 

The  various  preparations  of  iodine  have  been  considered  very 
serviceable,  but  their  virtues  to  some  extent,  have  been  over-esti- 
mated. In  the  first  stage  their  utility  is  greatest.  When  given 
in  large  doses  they  sometimes  produce  irritation  of  the  stomach. 
This,  however,  may  be  .prevented  by  giving  in  conjuction  with 
the  remedy,  sugar.  Their  operation  when  favorable,  tends  to 
produce  absorption,  an  object  always  to  be  sought  in  the  incipient 
stage  of  phthisis.  Whenever  either  by  remedies  or  by  prophylac- 
tic means,  we  can  cause  absorption  to  exceed  deposition,  a  curative 
process  is  commenced,  whose  continuance  will  result  in  restora- 
tion. Lugol's  preparation  of  iodine  is  perhaps  as  good  as  any. 
It  should  be  taken  in  a  large  proportion  of  water  or  half  a  pint  of 
some  demulcent  drink,  well  sweetened  with  sugar.  Various  other 
remedies  have  been  used  at  different  times,  to  enumerate  which 
would  be  entirely  useless.  Prof.  C.  Newton  sometimes  adminis- 
tered equal  parts  of  common  salt  and  precipitated  carbonate  of 
iron,  beat  up  with  an  egg.  The  amount  of  the  two  former  arti- 
cles should  be  from  two  to  three  drachms  a  day. 

It  is  not  so  much  my  object  to  tell  what  is  not  as  what  is  use- 
ful in  the  treatment  of  phthisis.  To  me,  however,  there  seems 
to  be  a  necessity  for  caution  in  the  use  of  narcotics  in  the  first 
stage  of  this  disease.  Their  operation  is  directly  adverse  to  the 
promotion  or  restoration  of.  the  secretions,  absorptions,  and  exhal- 
ations of  the  system.  Internal  engorgments  are  increased  by 
their  use,  even  in  small  doses;  and  every  post  mortem  examina- 
tion in  subjects  destroyed  by  narcotics,  shows  a  violent  state  of 
congestion  in  the  internal  tissues  of  the  head,  thorax,  and  abdo- 
men similar  to  those  produced  in  the  internal  tissues  in  most  ma- 
lignant fevers.  Dr.  Gallup  observes,  "  If  compelled  to  use  lauda- 
num, Dover's  powders,  opiate  cordials,  or  cough  drops,  I  would 
never  attempt  a  radical  cure  of  phthisis  pulmonalis,  in  any  of  its 
varieties."  The  best  possible  way  to  produce  freedom  from  ner- 
vous irritation,  and  quiet  sleep,  is  to  restore  the  circulation  of  the 
blood  in  the  most  minute  capillary  vessels.  'A  warm  bath,  or  al- 
cohol and  vapor  bath,  properly  administered  at  bed  time,  and  fol- 
lowed by  friction,  will  secure  to  the  patient  more  natural  repose 
than  all  the  narcotics  ia  the  Materia  Medica. 

In  case  a  nervine  is  needed,  the  cypripedinm,  scutellaria  lupu- 


PHTHISIS.  363 

lin,  together  with  the  bath  will  be  sufficient.  Lobelia  tincture 
combined  with  either  one  or  more  of  the  above  articles,  will  often 
produce  a  still  better  anodyne  effect. 

In  this  disease  there  is  little  or  no  need  of  cathartics.  The 
tendency  of  the  mucous  membrane  of  the  intestines  to  become 
tuberculated,  and  ulcerated,  centra-indicates  their  use.  For  a 
mild  laxative,  a  cold  infusion  of  eupatorium  perfoliatum,  the  inspi- 
ssated gall  pill  recommended  in  the  article  on  pleuritis,  or  some 
other  mild  laxative  may  be  administered.  The  cod  liver  oil  usu- 
ally lias  a  tendency  to  overcome  costiveness. 

2.  To  obviate  the  effects  of  Tubercles. — The  development  of 
tubercles  in  the  parenchyma  of  the  lungs  gives  rise  to  the  rational 
symptoms,  to  modify  the  severity  of  which  during  the  last  stage 
is  all  that  human  means  can  effect. 

Cough. — When  this  becomes  very  troublesome,  entirely  pre- 
venting sleep,  means  should  be  used  to  allay  it.  Demulcents 
freely  given,  sometimes  prove  palliative.  Of  this  class  of  reme- 
dies, ulmus,  acacia,  flax-seed  etc.,  are  among  the  most  important. 
An  infusion  of  one,  or  all  these  articles  containing  a  little  licorice 
and  lemon-juice,  will  often  be  sufficient  to  assuage  the  violence  of 
this  symptom. 

In  case  the  disease  is  so  far  advanced  as  to  make  any  perman- 
ent improvement  entirely  hopeless,  sedative  and  narcotic  agents 
must  be  resorted  to.  The  dose  of  these  should  be  as  small  as 
possible  to  secure  the  desired  effect.  The  anodyne,  or  sedative, 
more  than  the  narcotic  power  should  be  sought.  Accordingly  my 
practice  is  to  combine  the  acetate  of  morphia  with  some  form  of 
lobelia,  or  with  inspissated  gall,  in  order  to  prevent  as  far  as  pos- 
sible the  narcotic  effect  of  the  opiate.  Five  or  six  grains  of  the 
latter  remedy — the  gall — neutralizes  the  constipating  and  narcotic 
elVects  of  one  grain  of  opium,  without  injuring  its  sedative  influ- 
ence. Digitalis  is  sometimes  useful  to  allay  arterial  excitement, 
and  to  mitigate  uneasy  sensations.  Dr.  Chapman  makes  the  fol- 
lowing statement  in  relation  to  this  remedy.  "As  the  result  of 
no  slender  experience  with  digitalis,  I  am  prepared  to  state,  that 
the  only  case  of  phthisis  in  which  it  can  be  much  relied  on,  is 
the  incipient  stage,  usually  attended  with  a  slight  haemoptysis, 
small,  quick,  irritated  pulse,  extreme  debility  of  the  system,  short 


364  THORACIC    DISEASES. 

impeded  respiration,  and  hard,  dry,  diminutive  cough,  where  evac- 
uent  means  are  precluded."  Lactucarium,  hyoscyamus,  conium, 
stramonium,  and  belladonna  may  be,  used  as  substitutes  for 
opiates. 

Dyspnoea. — So  far  as  this  is  dependent  upon  organic  lesion,  no 
permanent  benefit  can  be  derived  from  remedies.  But  whenever, 
either  partly  or  wholly,  it  arises  from  nervous  derangement,  ner- 
vine, sedative  and  narcotic  remedies  must  be  used.  Tincture  of 
lobelia  and  extract  of  stramonium,  are  often  serviceable.  Occa- 
sionally relief  may  be  obtained  by  the  inhalation  of  vapors — of 
tincture  of  conium,  or  of  the  smoke  of  stramonium,  or  vinegar 
of  lobelia. 

Hemoptysis. — In  case  this  arises  from  congestion,  an  anti-in- 
flammatory regimen  should  be  resorted  to, — that  is  the  use  of  lo- 
belia in  nauseating  doses,  the  application  to  the  chest  of  cold  alco- 
hol and  water,  the  use  of  baths  to  determine  the  blood  to  the  sur- 
face, which  in  too  great  a  quantity  flows  into  the  pulmonary  tis- 
sues. In  case  there  are  no  febrile  symptoms,  a  little  common  salt, 
taken  undissolved  into  the  mouth,  and  swallowed  in  that  state, 
will  often  at  once  check  the  hemorrhage.  Astringents  are  often 
of  great  utility,  especially  those  containing  styptic  properties. 
Tannic  acid,  kino,  rhatany,  and  matico  are  highly  recommended. 
Oil  of  turpentine  has  been  successfully  used  for  this  purpose.  The 
best  styptic  with  which  I  am  acquainted  is  the  geranin,  the  ac- 
tive principle  of  geranium  maculaturn.  This  in  severe  cases  of 
haemoptysis  given  in  doses  of  ten  grain  s  every  half  hour,  exerts  a 
very  beneficial  influence  upon  the  hemorrhage.  To  prevent  a  re- 
currence of  this  symptom,  an  infusion  of  lycopus  virginicus,  tril- 
lium,  and  geranium  maculaturn,  is  perhaps  the  best  means  that 
can  be  used.  Of  the  lycopus  virginicus,  as  a  remedy  for  haemop- 
tysis, Dr.  H.  Jacobs  of  Chicopee,  thinks  very  highly. 

Pectoral  Pains. — These  may  be  removed  or  assuaged  by  lin- 
iments of  various  kinds.  If  the  pain  is  of  a  rheumatic  character, 
bathing  the  side  in  a  liniment  composed  of  one  part  of  tincture 
of  capsicum,  and  four  of  tincture  of  arnica,  will  usually  give  re- 
lief. If  of  a  nervous  character,  the  tincture  of  aconite  in  a  suit- 
able proportion  may  be  added  to  the  above  mentioned  compound, 
and  applied  to  the  side.  In  case  the  pain  is  caused  by  pleuritic 


PHTHISIS.  365 

inflammation,  other  remedies  may  be  applied.  But,  in  my  opin- 
ion, all  powerful  irritants,  such  as  setons,  tartar-emetic  issues,  do 
more  injury  by  producing  constitutional  excitement,  than  good  by 
their  revulsive  effect.  If  any  thing  of  this  kind  is  used,  it  should 
be  the  irritating  plaster,  composed  of  some  adhesive  mixture  and 
podophyllum.  and  phytolacca.  These  latter  cutaneous  irritants, 
are  most  beneficial  in  those  cases  in  which  secondary  inflamma- 
tion, and  chronic  pleuritis  exist  with  effusion. 

All  the  liniments,  and  plasters  and  irritants  used  in  this  disease, 
should  not  supersede  the  application  of  water  and  alcohol  to  the 
chest.  Whenever  there  is  much  heat,  or  when  the  skin  is  dry, 
this  should  be  freely  applied,  the  temperature  of  the  application 
being  varied  according  to  the  heat  of  the  chest,  and  the  reacting 
power  of  the  system. 

Bronchial  Inflammation. — This  should  be  combatted  by  the 
use  of  relaxants  and  expectorants.  That  used  by  Prof.  Newton, 
the  compound  sirup  of  sanguinaria  and  lobelia  is  very  useful. 
The  extract  of  lobelia  pill,  should  be  given  to  lessen  the  general 
febrile  action,  and  proper  attention  directed  to  promote  cutaneous 
circulation  and  secretion. 

The  expectorant  compounds  should  be  varied  according  to  the 
exigencies  of  the  case.  No  one  formula  should  be  followed  in 
the  compounding  of  medicine  for  this  complication  of  phthisis. 
When  the  symptoms  are  somewhat  inflammatory,  the  preparation 
made  by  Dr.  G.  M.  Nichols,  is  as  useful  as  any  : — 

R          Sirnpi  glycyrrhizrc  §  ii.,* 

Sirupi  ipecacuanhas  5  vi., 
Tincturcc  sanguinaria} 

Tincturre  lobelisc       *         a  a  5  hi, 

Tincturce  opii  camphorafffi  5  iiss. 

Tincturrc  olei  gaultheria?  5  iss. 
Misce. 


cTor  the  preparation  of  the  sirup  of  glj'cyrrhiza,  no  directions  are  given  in  the 
U.  S.  Dispensatory.  .  It  may  be  prepared  by  macerating  the  bruised  root  in  water 
until  a  strong  infusion  is  obtained,  and  then  using  this,  instead  of  the  water,  in 
the  formula  for  preparing  the  sirupus  simplex,  in  the  U.  S.  Dispensatory. 


366  THORACIC    DISEASES. 

Dose, — one  teaspoonful  once  in  six  hours  or  oftener  in  case  the 
severity  of  the  symptoms  demand.  This  may  be  used  once  in  four 
hours,  alternately  with  a  two  grain  pill  of  extract  of  lobelia,  if 
there  is  high  febrile  excitement.  The  proportions  of  the  sub- 
stances in  the  formula,  should  be  altered  according  to  the  necessi- 
ties of  each  individual  case. 

When  the  bronchial  inflammation  assumes  an  asthenic  form, 
and  the  febrile  symptoms  are  much  less  manifest,  the  relaxant 
means  should  for  the  most  part  be  discontinued,  and  in  their  stead 
slightly  tonic,  stimulating  and  balsamic  remedies  should  be  used. 

Under  such  circumstances,  an  expectorant  compounded  accord- 
ing to  the  following  formula,  will  better  fulfill  the  indications  of 
treatment : — 

R         Sirupi  glycyrrhizce 
Sirupi  senegas 

Sirupi  pruni  virginianaj  a  a  §  i., 

Tincturce  sanguinarias 
Tincturas  lobelias  a  a          sii., 

Tincturso  germinum  pop.  balsamiferae  §  iv., 
Morphia?  sulphatis  gr.  i. 

Misce. 

Dose, — one  tea-spoonful  once  in  six  hours,  or  oftener  accord- 
ing to  the  exigences  of  the  case. 

With  the  more  stimulating  expectorants,  tonics  may  be  combin- 
ed. In  anamiic  cases,  attended  with  amenorrhosa  and  gastric  irri- 
tation the  compound  mixture  of  iron  of  the  Pharmacopoeia,  may 
be  given  either  alternately  or  combined  with  expectorants. 

The  inhalation  of  certain  substances  is  often  of  some  benefit. 
The  vapor  of  tar,  is  highly  esteemed  by  some  physicians.  The 
air  of  the  sleeping-room  of  the  patient  may  be  impregnated  with 
it  by  placing  a  little  tar  in  a  cup  which  is  to  be  immersed  in 
water,  contained  in  another  vessel,  and  heated  by  a  spirit  lamp.' 
The  common  nurse  lamp  answers  this  purpose  very  well.  The 
inhalation  of  chlorine  and  iodine,  is  somewhat  irritating  to  the 
lungs.  With  the  chlorine  the  air  may  be  impregnated  by  letting 
some  sulphuric  acid  fall  drop  by  drop  on  chloride  of  lime.  Am- 
monia has  also  been  inhaled  for  a  similar  purpose. 


PHTHISIS.  367 

"  In  order  to  saturate  the  system  with  ammoniacal  gas  and  at 
the  same  time  to  acquire  an  increment  of  the  electric  fluid,  the 
following  method  of  application  may  be  used.  Take  a  piece  of 
quick  lime  as  large  as  a  playing  marble  and  pour  over  it  water 
suificient  to  slake  it,  so  that  it  will  fall  into  fine  powder.  Rub 
this  powder  in  a  mortar  with  a  piece  of  sal-ammoniac — muriate 
of  ammonia— as  large  as  a  piece  of  lime  till  the  articles  are  finely 
pulverized  and  mixed.  Put  the  powder  in  a  small  vessel,  and 
pour  in  a  pint  of  boiling  water.  Set  the  vessel  in  an  empty  box,  so 
that  the  vapor  can  be  inhaled  at  a  little  distance  from  the  vessel. 
Put  in  the  water  a  piece  of  heated  iron  to  make  it  boil  and  throw 
off  vapor.  Let  the  patient  inhale  the  vapor  for  half  an  hour." 
[Dr.  Win.  Tell  Parker.} 

Niglit-sweats  and  Hectic  Fever. — Since  the  night-sweats  are 
caused  by  debility  of  the  capillaries,  tonic  and  stimulating  reme- 
dies are  indicated  to  effect  their  suppression.  Among  the  inter- 
nal remedies  most  efficient  are  the  mineral  acids,  and  especially 
the  sulphuric  which  is  usually  employed  in  the  form  of  elixir  of 
vitriol,  or  the  aromatic  sulphuric  acid  of  the  Pharmacopoeia.  From 
five  to  fifteen  drops  may  be  administered  in  cold  water,  three  or 
four  times  a  day.  The  internal  administration  of  astringents  is 
sometimes  of  use.  Among  these,  alum,  and  tannic  acid  are  per- 
haps as  good  as  any.  But  the  best  remedy  that  can  be  applied, 
is  a  liot  bat /i,  made  excitant  by  the  addition  of  capsicum,  mustard 
o.nd  common  salt.  It  should  be  followed  by  brisk  friction  with  a 
solution  of  alum  in  hot  brandy  in  the  proportion  of  two  drachms 
to  a  pint. 

M.  Delioux  highly  recommends  the  tannate  of  quinine  for 
arresting  night-sweats.  The  quantity  which  he  prescribes  is  from 
seven  to  fifteen  grains  daily,  dividing  it  into  three  or  four  doses, 
taken  at  intervals,  the  last  being  taken  three  or  four  hours  before 
sleep. 

An  efficient  remedy  is  the  following  : — 

1%          Acidi  sulphurici  aromatic  i  §  i. 

Quinie  sulphatis  £)i., 

Misce. 

Dose, — from  fifteen  to  twenty  drops,  t\vo  or  three  times  per 
day,  administered  in  a  wine-glassfull  of  cold  sage  tea. 


368  THORACIC    DISEASES. 

For  hectic  paroxysms,  no  remedies  are  more  effectual  than 
sulphate  of  quinine,  and  the  salicin,  the  active  principle  of  the 
salix. 

Vomiting  and  Diarrhoea. — These  symptoms  are  sometimes 
very  troublesome.  The  vomiting  is  often  one  of  the  most  obsti- 
nate symptoms,  and  very  seldom  yields  to  the  influence  of  reme- 
dies. The  amount  of  food  taken  at  a  time  should  be  reduced  to 
a  small  quantity.  Sometimes  lime-water  gives  temporary  relief. 
A  sinapism  applied  over  the  epigastrium  is  often  serviceable.  Di- 
arrhoea is  another  symptom  which  cannot  be  remedied  perma- 
nently by  medicine.  Dr.  Parrish  considered  a  milk  diet  good  to 
prevent  its  development.  The  most  benefit  that  can  be  derived 
may  be  had  from  the  administration  of  a  powder  containing  two 
drachms  of  myricin  and  one  of  geranin;  or  tannic  acid  given  in 
two  or  four  grain  doses  once  in  four  hours.  With  this,  alternate- 
ly, in  very  obstinate  cases,  opiates  may  be  administered. 

When  the  debility  is  great,  and  there  evidently  is  a  large  col- 
lection of  purulent  matter  in  the  bronchial  tubes  to  be  thrown  off 
by  expectoration,  and  yet  not  power  enough  in  the  system  to 
effect  this,  the  carbonate  of  ammonia,  will  prove  to  be  a  useful 
remedy.  Wine  whey  should  also  be  given  to  sustain  the  system. 
For  a  similar  purpose  milk  punch  and  wine  should  be  used. 

Various  other  remedies  have  been  used  by  the  profession.  In- 
haling tubes  have  been  invented  the  utility  of  which  has  not 
been  very  great.  Forcible  expansion  of  the  lungs  should  be 
chiefly  practised  in  the  early  stages,  and  especially  in  those  cases 
in  which  pleuritic  effusion  has  pressed  upon  one  or  both  of  the 
lungs,  and,  to  a  certain  extent,  destroyed  their  functions.  Jeffries' 
Respirator  has  been  highly  recommended  in  phthisis.  Its  benefit 
arises  from  the  power  of  the  instrument  to  prevent  the  entrance 
of  very  cold  air  into  the  lungs.  In  cold  weather  those  having 
irritable  lungs  need  something  of  this  kind  in  order  to  prevent 
the  ingress  of  very  cold  air,  until  it  is  heated.  The  instru- 
ment consists  of  a  fine  wire  gauze  which,  during  expiration 
becomes  heated  by  the  passing  breath,  and  that  heat  so  received, 
serves  to  warm  the  air  of  inspiration. 

The  treatment  of  the  several  varieties  of  phthisis  should  be 
-ssentially  the  same  as  that  laid  down  in  the  general  treatment. 


PULMONARY    CAXCER.  369 

In  the  acute  variety,  remedies  should  be  applied  with  more  vigor, 
especially  when  the  disease  is  somewhat  inflammatory.  The 
chronic  variety  needs  a  longer  course  of  alteratives,  and  general 
tonics,  nourishing  diet,  and  the  temperate  use  of  wine,  porter,  or 
ale.  In  this  variety  there  is  more  hope,  and  therefore,  the  physi- 
cian should  take  the  greatest  care  to  keep  up  an  equable  circula- 
tion of  the  blood,  to  induce  the  patient  to  take  exercise,  and  to 
associate  with  cheerful  company.  These  remarks  apply  equally 
well  to  the  latent  form  of  the  disease. 

The  phthisis  of  children  should  be  treated  with  general  tonics 
and  alteratives,  combined  with  the  sirup  of  the  iodide  of  iron. 
All  these  means  without  free  exercise  in  the  open  air  and  good 
substantial  food,  and  a  proper  attention  to  the  functions  of  the 
digestive  organs  and  the  cutaneous  secretion,  will  be  ineffectual. 
In  fine,  the  hygienic  and  dietetic  means  are  of  primary  impor- 
tance, the  medicinal  of  secondary. 


CHAPTER  XVI. 

P  U  L  M  0  N  A  R  Y    CANCER. 

Besides  tubercle  there  is  another  hetcrologous  deposit  in  the 
lungs,  called  carcinoma  or  cancer.  This  very  seldom  occurs, 
even  among  those  who  have  died  of  the  disease  in  other  parts  of 
the  body.  M.  Tanchou  states  that  out  of  9118  deaths  from 
cancer,  there  were  only  seven  cases  of  cancer  of  the  lungs.  Most 
frequently  pulmonary  cancer  has  its  seat  in  the  cellular  tissue. 
The  encephaloid  variety  is  most  common.  Out  of  twenty  cases, 
sixteen  wore  of  this  variety ;  three  encephaloid  and  scirrhus  united, 
one  scirrhus  and  colloid. 

Sometimes  the  cancerous  matter  is  deposited  in  the  cellular 
tissue  of  the  anterior  and  posterior  mediastinum,  and  forms  a 
tumor  which  presses  upon  contiguous  structures,  upon  the  trachea, 
great  blood-vessels  of  the  heart,  and  upon  the  oesophagus.  The 
tumor  sometimes  grows  to  so  great  a  size  as  to  distend  the  parietes 
of  the  chest. 

47 


6t(j  THORACIC    DISEASES. 

When  the  disease  is  located  in  the  pulmonary  tissue,  it  converts 
the  parenchyma  of  the  lung  into  its  own  substance.  Th'e  effect 
of  its  extension,  is  to  compress  adjacent  textures,  and  to  produce 
an  actual  atrophy  of  the  diseased  lung.  The  progress  of  the 
disease  may  excite  secondary  inflammation  ;  sometimes  implicating 
the  pleura.  Cancer,  like  tubercle,  sometimes  has  a  period  of  soft- 
ening, during  which  it  not  nnfrequently  excites  bronchitis.  But 
the  softened  masses,  unlike  tubercles,  are  seldom  expectorated. 

The  duration  of  cancer  of  the  lungs  is  usually  about  fourteen 
mouths.  But  it  may  terminate  life  in  two  months,  or  may  linger 
in  its  progress  until  years  pass  away.  Cancer  of  the  mediastinum 
seldom  terminates  so  speedily,  as  that  of  the  lungs  :  its  average 
duration  being  sixteen  months.  Pulmonary  cancer  is  divided  into 
two  varieties  :  cancer  of  the  lungs,  and  cancer  of  the  mediastinum. 

e>     i 

PATHOLOGY. — The  general  appearance  of  encephaloid  disease, 
is  that  of  -a  brain-white  solid  of  varying  consistence,  with  a  pinker 
hue  than  that  of  tubercle,  occurring  in  tumors  sometimes  en- 
cysted, or  infiltrated  through  the  tissue  of  the  lung.  Sometimes, 
the  tumors  are  soft,  and  cellular  ;  sometimes  tough,  resembling 
the  pancreas  in  appearance.  A  predominance  of  the  vascular,  and 
cellular  structure,  with  patches  of  extravasated  blood,  constitutes 
the  fungus  hasmatocles.  Encephaloid  matter  infiltrated  into  the 
parenchyma  of  the  lung,  in  some  cases,  presents  an  appearance 
intermediate  between  those  of  tuberculous  and  hepatized  consoli- 
dations. Sometimes  inelanosis  is  combined  with  encephaloid  dis- 
ease. The  black  matter  may  occur  infiltrated  in  a  natural  struc- 
ture or  in  distinct  tumors  or  deposits  of  an  irregular  cellular  or- 
ganization. Care  is  necessary,  in  order  not  to  confound  with 
inelanosis,  the  accumulations  of  black,  pulmonary  matter,  which 
take  place  to  a  great  extent  in  the  lungs  of  old  people,  especially 
among  the  inhabitants  of  large  towns.  This  black  appearance- 
is  supposed  to  be  caused  by  the  inhalation  of  particles  of  dust,  of 
a  carbonaceous  nature  from  the  atmosphere. 

DIAGNOSIS. — In  the  commencement  of  this  disease  there  are  no 
very  manifest  symptoms  developed.  There  may  bd  a  little  dyspnoea, 
slight  cough,  and  a  little  expectoration.  With  the  advance  of 


PULMONARY    CANCER.  371 

the  disease  the  symptoms  become  more  marked,  the  cough  is  in- 
creased, the  expectoration  is  more  copious,  and  there  is  an  almost 
constant  pain  in  the  chest.  Haemoptysis,  too.  may  occur,  in  con- 
sequence of  the  lesion  of  the  pulmonary  vessels.  The  constitu- 
tion sympathizes  with  the  local  disease  ;  the  pulse  is  excited,  there 
are  emaciation,  increasing  debility,  and  a  peculiar  straw  color  to  the 
countenance,  and  the  superficial  veins  become  enlarged.  Dropsical 
swelling  is  observable  in  the  extremities,  and  the  system  gradually 
sinks  under  a  low.  asthenie  form  of  inflammation — going  on  in 
the  chest  or  abdomen.  The  cancerous  deposit,  gives  rise  to  dull- 
ness on  percussion,  sometimes  to  bronchial  respiration,  and  vocal  re- 
sonance, or  to  a  ronchus  and  mucous  rale.  The  cancerous  disease 
tends  to  produce  contraction  of  the  affected  side,  which,  of  course, 
is  porportioned  to  the  extent  to  which  the  disease  has  progressed. 
The  pulmonary  tissue  becomes  condensed  and  the  bronchi  some- 
times are  obliterated,  in  which  cases  there  will  be  no  respiratory 
murmur. 

CANCER  OF  THE  MEDIASTINUM. — PATHOLOGY. — The  growth  of 
the  tumor  may  be  so  great  as  to  compress  the  vessels  of  the  heart, 
and  induce  sinus  of  valvular  disease,  or  by  retarding  the  free  cir- 
culation of  the  blood  may  produce  oedema,  or  may  fill  so  large  a 
space  in  the  chest  as  to  cause  the  physical  signs  of  an  empycma. 
These  cancerous  tumors  vary  in  size,  sometimes  weighing  several 
pounds.  They  present  the  three  forms  of  cancerous  growths. 

THE  DIAGNOSIS  of  cancer  of  the  mediastinum  is  difficult.  There 
are  only  a  lew  distinctive  symptoms,  among  which  are  the  straw 
color  of  the  skin,  the  codema  of  the  face,  and  upper  extremities, 
a  tendency  to  anasarca  in  the  lower  limbs:  cancerous  tumors  on 
other  parts  of  the  body,  the  contraction  of  the  side  accompanied 
by  bronchial  respiration,  heard  over  it,  instead  of  the  dilatation  so 
characteristic  of  hydrothorax,  and  empyema. 

Phthisis  usually  affects -the  upper  parts  of  the  lungs:  cancer 
may  attack  any  portion,  although  it  oftener  affects  the  upper  por- 
tions, than  the  lower.  Neuralgic  pain  often  extends  down  the 
arm.  which  is  not  the  case  in  phthisis.  The  pulse  is  also  less  ex- 
cited, hectic  seldom  severe,  cavities  arc  not  formed.  Tubercles 
in  general  before  the  case  terminates  fatally,  affect  both  lungs, 


372  THOHACIC    DISEASES. 

while  cancer  usually  affects  one  only.  Cancerous  tumors  are 
usually  larger  than  those  of  a  tubercular  nature.  This  disease 
may  simulate  thoracic  aneurism  or  even  disease  of  the  heart. 
This  results  from  its  location  near  some  large  blood-vessel,  in 
which  case  it  may  obstruct  the  flow  of  blood,  and  hence,  produce 
those  physical  conditions  which  excite  the  bellows  murmur.  Its 
recognition  under  such  circumstances  must  depend  upon  the  exis- 
tence of  the  cancerous  tendency  in  the  general  system.  The 
heart  is  not  so  enlarged  as  in  hypertrophy.  From  aneurism  it 
may  sometimes  be  distinguished  by  its  location : — aneurism  being 
on  the  course  of  the  aorta,  and  being  attended  by  pulsation,  a 
thrill  and  bellows  murmur ;  cancer  is  not  prone  to  give  rise  to 
these  phenomena.  It  is  evident,  however,  that  nothing  very  defi- 
nite can  be  determined  by  the  symptoms  in  those  cases  in  which 
complications  exist ;  and  under  the  most  favorable  circumstances 
the  diagnosis  must  be  uncertain. 

The  Prognosis  may  lie  readily  inferred  from  the  fatal  results 
following  cancerous  disease  in  other  parts  of  the  body. 

The  Treatment  must  be  almost  wholly  palliative ;  the  great 
object  is  this ;  to  remove  urgent  symptoms  by  sedative  and  re- 
laxing agents.  Complications  should  be  treated  according  to  the 
nature  of  the  disease  with  which  it  is  associated.  Dyspeptic 
symptoms  should  be  removed  by  gentle  emetics  of  lobelia,  and 
by  tonics.  To  purify  the  blood  the  best  alteratives  may  be  used 
in  conjunction  with  other  means,  to  produce  a  normal  action  of 
the  cutaneous  vessels. 


DISEASES    OF    THE    HEART.  373 

DIVISION  II. 

DISEASES    OF    THE    HEART. 

Formerly,  diseases  of  the  heart  were  very  imperfectly  under- 
stood. In  their  organic  forms  they  have  been  considered  very 
rare,  and  their  results  almost  always  fatal.  Very  frequently  they 
have  been  confounded  with  other  diseases  of  the  thorax,  such  as 
pulmonary  congestion,  and  hydrothorax,  and  sometimes  with  those 
of  other  parts  of  the  system,  such  as  dropsy  and  apoplexy,  and  va- 
rious other  affections.  By  the  discoveries  of  Corvisart,  Laennec, 
Louis,  Cullen,  and  Bouillaud,  in  France  ;  of  Hope,  Williams,  La- 
tham and  Stokes  of  Great  Britain,  and  of  Dr.  Pennock  of  this 
country,  the  nature  of  cardiac  diseases,  and  their  diagnosis  and 
treatment,  are  now  made  as  intelligible  as  that  of  the  majority  of 
other  diseases. 

Before  the  discovery  of  auscultation,  diseases  of  the  heart 
could  not  without  great  difficulty  be  distinguished  from  those  ot 
the  lungs.  But  physical  exploration,  and  pathological  anatomy 
have  to  a  considerable  extent  removed  the  impediments  to  their 
diagnosis.  The  investigations  into  their  causes  have  also  pro- 
duced many  valuable  results,  and  have  clearly  shown,  that  in  a 
majority  of  cases  especially  in  young  persons  they  arise  from  in- 
flammation. 

General  symptoms. — The  pulse  is  nearly  synchronous  with  the 
pulsation  of  the  heart,  following  it  at  a  very  slight  interval.  Sub- 
ject to  all  the  irregularities  of  the  cardiac  pulsations  in  relation  to 
duration  and  irregularity  of  beat,  it  often  enables  us  to  detect  the 
derangement  of  the  central  organ  of  the  circulation. 

But  it  is  not  always  a  sure  indication.  Intermission  of  the 
pulse  may  exist,  when  there  is  none  in  the  heart.  The  ventricu- 
lar contraction  may  be  too  feeble  to  transmit  the  impulse  along 
the  arteries  of  the  extremities.  The  quantity  of  blood  in  the 
heart  may  be  so  small  as  not  to  cause  vigorous  contraction,  and  a 
feeble,  irregular  pulse  may  be  the  consequence.  Irregularities  of 


374  THORACIC    DISEASES. 

• 

the  pulse  independent  of  cardiac  disease  may  exist  for  a  long 
time,  but  caeteris  paribus  they  are  more  apt  to  occur  in  connection 
with  it,  than  independent  of  it. 

Dyspnoea  is  another  symptom  of  cardiac  disease.  Sometimes 
it  is  partly  dependent  upon  nervous  derangements,  bat  more 
often  upon  direct  interference  with  the  functions  of  the  lungs, 
either  by  pressure  upon  that  organ,  or  effusion  into  the  parenchy- 
/natous  tissue  or  pleural  sac. 

Pain. — In  disease  of  the  heart,  painful  or  disagreeable  sensations 
often  occur  in  the  cardiac  region.  Sometimes  it  is  very  acute, 
felt  near  the  left  nipple  or  at  the  extremity  of  the  sternum.  This 
is  sometimes  attended  with  dyspnoea  ;  sometimes  extending  across 
the  chest  and  passing  down  the  left  arm. 

Palpitations,  which  are  pulsations  so  violent  as  to  be  trouble- 
some to  the  patient,  are  often  experienced  in  disease  of  the  heart. 
They  arise  from  nervous  irritability  in  which  case  they  are  often 
the  cause  of  needless  fear  to  the  patient,  and  sometimes  of  per- 
plexity to  the  physician.  This  symptom,  unless  attended  with 
other  indications  of  cardiac  disease  should  not  be  much  depended 
upon ; — for  when  alone,  it  presages  no  certain  organic  derange- 
ment, and  should  excite  suspicion  only  when  it  continues  for  a 
long  time. 

The  secondary  symptoms  resulting  from  cardiac  disease  are  nu- 
merous, and  such  as  would  naturally  result  from  irregularities  of 
the  circulation  of  the  blood.  The  blood  may  be  driven  with  too 
great  force  into  the  brain,  as  in  hypertrophy  of  the  left  ventricle, 
into  the  lungs  in  a  similar  condition  of  the  right  ventricle,  or  it 
may  be  retarded  in  its  return  from  the  abdominal  viscera  by  im- 
pediments in  the  right  side  of  the  heart,  and  finally  it  may  be 
feebly  propelled  throughout  the  entire  system  in  consequence  of 
the  cardiac  obstruction.  Hence,  congestions  in  one  organ,  and 
'anaemia  in  others  ;  hence  apoplexy,  vertigo,  cpistaxis  and  haema- 
temesis  occur.  These  symptoms  vary  according  to  Urn  nature  of 
the  cardiac  disease,  the  constitution  of  the  patient,  and  various 
other  modifying  circumstances.  If  active  congestion  is  present, 
\vo  have  the  turgid,  distended  state  of  the  blood-vessels,  the  prom- 
inent eye,  the  flushed  and  swollen  face;  if  the  passive,  then  we 
have  the  purple  lips,  livid  complexion,  and  the  general  tendency 


DISEASES    OF    THE    HEART.  375 

• 

to  oedema.     The  whole  heart  is  seldom  diseased  at  once.     It  may 
be  confined  to  a  single  valve  or  cavity. 

'Causes  of  Heart  Disease. — Inflammation,  attacking  the  mem- 
branes of  the  heart,  whether  external  or  internal,  becomes  a  fre- 
quent cause  of  cardiac  lesions.  Pericarditis  has  but  little  tendency 
to  produce  organic  changes,  while  endocarditis  is  very  prone  to 
produce  such  a  result.  Of  all  the  causes  tending  to  produce  dis- 
ease of  the  heart,  acute  articular  rheumatism  is  the  most  frequent. 
More  than  half  the  cases  of  this  variety  of  rheumatism,  accord- 
ing to  Dr.  Gerhard,  are  more  or  less  complicated  with  cardiac  dis- 
ease. 

There  are  other  causes,  which,  although  not  so  important  as  the 
one  above  mentioned,  arc,  nevertheless,  worthy  of  notice.  These 
are  violent  nervous  excitement,  sudden  injuries  inflicted  by  a 
strain,  a  sudden  propulsion  of  the  blood  into  the  heart  in  an  ab- 
normal quantity  and  with  great  force,  advanced  age,  ossific  deposits 
in  the  valves  or  internal  membranes. 

Functional  diseases  of  the  heart  are  produced  by  causes  as  vari- 
ous as  those  of  all  nervous  disorders.  In  general  anaemia,  ner- 
vous irritability,  gastric  derangements,  and  a  suppression,  or  inter- 
ruption of  the  menstrual  discharge,  give  rise  to  violent  palpita- 
tions. In  young  men.  particularly  those  of  a  nervous  tempera- 
ment, of  studious  habits,  accustoming  themselves  to  excess  in 
study,  the  same  scries  of  symptoms  is  sometimes  developed. 

Termination  of  Heart  Disease. — Inflammatory  affections  of 
the  heart  may  terminate  in  recovery,  and  the  patient  experience  a 
complete  restoration  to  health.  Dr.  Hope  remarks: — "Many 
think  that  the  expectation  of  effecting  an  improvement  in  the 
treatment  of  diseases  of  the  heart,  is  chimerical ;  and  they  think 
so.  because,  not  being,  accustomed  to  recognize  the  diseases  in 
question  before  they  have  attained  an  advanced  stage,  they  are 
preoccupied  with  the  old  and  popular  idea  of  their  incurability. 
To  such  it  might,  perhaps,  be  a  sufficiently  philosophical  answer 
to  reply,  that  an  improved  knowledge  of  the  nature  and  causes  of 
a  disease,  must  alone  necessarily  lead  to  an  improvement  in  the 
treatment,  and  that  therapeutic  weapons  are  dangerous,  when 
wielded  in  the  dark.  Rut  here  we  may  go  much  farther  ;  we  may 
say  that,  by  the  improved  means  of  diagnosis,  the  maladies  under 


376  THORACIC    DISEASES. 

consideration,  may  be  recognized,  not  only  in  their  advanced,  but 
in  their  incipient  stages,  and  even,  when  so  slight  as  to  constitute 
little  more  than  a  tendency.  We  may  say,  on  the  ground  of  in- 
contestable experience,  that,  in  their  early  stages,  they  are,  in  a 
large  proportion  of  instances,  susceptible  of  a  perfect  cure,  and 
that,  when  not,  they  may  in  general  be  so  far  counteracted  as 
not  materially,  and  sometimes  not  at  all,  to  curtail  the  existence 
of  the  patient.  We  may,  accordingly,  predict  that  the  term  "  dis- 
ease of  the  heart."  which  at  present  sounds  like  a  death  knell 
when  uttered  by  the  physician,  will  hereafter  become  by  familiar- 
ity, not  more  alarming  than  the  term  asthma,  under  which  it  is 
frequently  disguised." 

This  description  of  the  curability  of  disease  of  the  heart,  is 
somewhat  too  hopeful.  Chronic  organic  affections  in  "general  do 
not  terminate  so  favorably.  They  may  continue  for  years,  not 
increasing  in  severity,  until  some  exciting  cause  adds  new  force  to 
the  disease  and  causes  sudden  death.  When  once  the  disease 
has  commenced  on  the  internal  membrane,  it  is  prone  to  extend ; 
one  difficulty  leads  on  to  another;  hypertrophy  produces  valvular 
disease  and  inflammation  of  the  endocardium.  So  that,  when 
endocarditis  in  the  young  ends  in  apparent  recovery  from  the  acute 
attack,  it  leaves  behind  in  most  cases  a  disease  in  the  valves 
which,  by  impeding  the  circulation  of  the  blood,  produces  an  un- 
natural action  of  the  heart,  and  at  last  terminates  in  disease  of 
the  muscular  tissue. 

Functional  disease  of  the  heart  is  seldom  dangerous,  except  in 
those  cases  in  which  it  generates  organic  affections.  The  influ- 
ence of  age  is  considerable  in  the  production  of  cardiac  disease. 
Cardiac  affections  are  usually  slow  in  their  access,  and  consequently 
they  are  more  often  observed  in  the  old  than  in  the  young.  They 
also  depend  for  their  production,  upon  that  feeble  circulation  of 
the  blood  arising  from  deficient  nutrition,  which  is  more  frequent 
in  the  aged.  On  account  of  their  greater  exposure,  males  are 
more  subject  to  organic  diseases  of  the  heart  than  females.  Their 
frequent  muscular  exertions  both  in  labor  and  amusement,  tend  to 
produce  permanent  lesions.  ,  The  functional  derangements  of  the 
heart,  are  more  common  in  females  than  in  males,  because  they 
are  more  subject  to  symptomatic  affections,  on  account  of  their 
greater  nervous  irritability. 


EXAMINATION    OF    THE     HEART.  377 

GENERAL  DIAGNOSIS. — The  nature  of  the  origin  of  the  disease, 
has  important  bearings  on  its  diagnosis.  If  inflammation  of  a 
rheumatic  character  preceded  the  attack,  if  disease  of  the  heart  is 
hereditary,  or  if  the  gouty  or  rheumatic  diathesis  is  fully  devel- 
oped, then,  the  existence  of  organic  affections  of  the  heart  should 
very  strongly  be  suspected.  But  if,  on  the  other  hand,  there 
were  peculiar  marks  of  deranged  nervous  action  preceding  the 
cardiac  symptoms,  a  probability  exists,  that  the  case  is  one  of 
functional,  not  of  organic-disease.  To  this  probability  is  added 
more  evidence,  if  the  patient  presents  strong  signs  of  a  nervous 
temperament. 

Pain  in  the  region  of  the  prascordia,  and  a  sensation  of  weight 
and  stricture  there  felt,  are  indications  of  this  disease ;  likewise, 
orthopncea.  fullness  of  the  cervical  veins,  increased  dyspnoea  in 
ascending  a  hight,  blueness  or  lividity  of  the  lips.  A  thrilling 
pulse,  and  cedematous  effusions  are  also  somewhat  characteristic. 
< 

GENERAL  PROGNOSIS. — In  organic  disease  of  the  heart  the  prog- 
nosis is  unfavorable.  The  effects  of  extensive  disorganization  of 
the  valves,  and  of  the  internal  membrane  of  the  heart  and  aorta, 
and  of  hypertrophy  and  dilatation  must  from  the  nature  of  all 
such  changes  be  attended  with  danger  to  life.  In  acute  inflam- 
matory cases,  the  proper  application  of  appropriate  remedies  gen- 
erally gives  relief;  sometimes  very  soon,  sometimes  after  a  longer 
period.  In  those  cases  which  seem  to  presage  a  fatal  termination, 
the  symptoms  sometimes  abate  by  degrees,  until  the  disease  is 
finally,  so  far  as  external  phenomena  can  be  perceived,  verging 
on  towards  a  cure.  The  prognosis  then  must  depend  upon  the 
character  of  the  modifying  circumstances,  and  not  upon  any  one 
symptom  exclusively. 


CHAPTER  I. 

EXAMINATION    OF    THE    HEART, 

In  making  an  examination  of  the  heart,  several  points  need  par- 
ticular attention.     The  most  important  of  these  are  its  positioa 
48 


378  THORACIC    DISEASES. 

size,  impulsion,  sounds,  rhythm,  and  the  mode  in  which  the  heart 
acts,  whether  regularly  or  spasmodically.  , 

POSITION  or  THE  HEART.- — The  heart  lies  in  the  centre  of  the 
chest,  inclining  a  little  to  the  left  side  and  to  the  lower  portion  of 
the  sternum.  Its  direction  is  oblique  from  right  to  left.  Superi- 
orly, it  extends  to  the  intercostal  space  between  the  third  and 
fourth  ribs ;  inferiorly  to  the  base  of  the  thorax,  or  to  about  the 
ninth  dorsal  vertebra.  To  the  left  it  extends  nearly  or  quite  to 
the  nipple,  to  the  right  it  extends  a  little  beyond  the  edge  of  the 
sternum.  The  apex  is  between  the  cartilages  of  the  fifth  and  sixth 
left  ribs,  at  a  point  about  two  inches  below  the  nipple,  and  one 
inch  on  its  sternal  side.  The  base  of  the  ventricles  corresponds 
nearly  with  the  middle  of  the  third  rib.  According  to  Dr.  Pen- 
nock,  the  only  fixed  and  stationary  point  is  at  the  valves  of  the 
aorta ;  other  parts  being  movable  more  or  less  around  that  as  a 
centre.  And,  therefore,  the  exact  situation  of  those  valves — the 
aortic  semilunar — becomes  of  some  importance.  A  needle  pierc- 
ing the  middle  of  the  sternum  opposite  to  the  middle  of  the  car- 
tilages of  the  third  ribs,  and  perpendicular  to  the  plane  of  the 
sternum  will  pierce  them.  A  needle  introduced  perpendicular  to 
the  tangent  of  the  curved  surface  of  the  thorax,  between  the  car- 
tilages of  the  second  and  third  ribs,  half  an  inch  from  the  left 
margin  of  the  sternum,  pierces  the  semilunar  valves  of  the  pul- 
monary artery. 

"  The  septum  between  the  ventricles,  coincides  with  the  osse- 
ous extremities  of  the  third  and  fourth  and  fifth  ribs,  and  on  the 
fourth  rib  is  midway  between  the  left  margin  of  the  sternum  and 
nipple."  The  positions  of  the  orifices  of  the  aorta  and  pulmonary 
artery,  of  course,  correspond  very  nearly  with  those  of  their 
valves,  the  valves  being  situated  a  little  superior.  The  left  auric- 
ulo  ventricular  orifice,  is  under  the  lower  edge  of  the  cartilage  of 
the  third  rib,  and  a  little  to  the  left  of  the  median  line.  The 
memory  of  these  facts  is  very  necessary  in  the  diagnosis  of  valv- 
ular disease.  The  heart  is  in  contact  with  the  diaphragm  below, 
and  the  lungs,  on  its  right  and  left  sides  overlap  it,  leaving  a  small 
triangular  space  uncovered,  of  variable  dimensions,  under  the  car- 
tilages of  the  fourth  and  fifth  ribs  of  the  left  side. 


EXAMINATION    OF    THE    HEART.  379 

Size  of  the  Heart. — Much  care  has  been  taken  to  obtain  by  ac- 
curate observation  the  exact  size  of  the  heart.  Laennec  com- 
pared its  size  with  that  of  the  fist  of  the  individual.  This, 
though  a  simple  comparison,  and  one  which  may  always  be  easily 
made,  is  by  no  means  accurate.  Others  have  with  great  precision, 
weighed  the  heart,  and  brought  forth  the  conclusion  that  its  weight 
is  about  seven  or  eight  ounces.  It  is  always  greater  in  males, 
than  in  females.* 

Bizot  in  order  to  arrive  at  a  still  greater  degree  of  precision, 
has  adopted  the  method  of  measuring  the  heart.  His  conclu- 
sions are,  that  the  heart  increases  in  size  as  age  advances,  that  its 
size  corresponds  with  the  breadth  of  the  shoulders,  and  not  with 
the  height  of  the  individual,  that  it  is  larger  in  males  than  in 
females. 

To  ascertain  the  normal  size  of  the  orifices,  is  very  important. 
Dr.  Taylor  has  suggested  a  method  of  very  easy  application. 
The  mitral  orifice  just  admits  according  to  his  measurement,  the 
first  two  fingers  of  the  hand ;  the  tricuspid  orifice,  the  three  first 
fingers.  This,  like  the  comparison  of  Laennec,  is  not  accurate, 
but  is  of  some  practical  utility,  where  great  precision  is  not  nec- 
essary. 

In  order  to  ascertain  whether  the  valves  will  close  the  orifices 
the  experiment  suggested  by  Dr.  Swett,  is  useful  and  conclusive. 
Having  removed  an  inch  or  two  of  the  aorta  and  pulmonary  arte- 
ry with  the  heart,  he  then  makes  a  transverse  section  of  the  heart 
near  the  apex,  so  as  to  open  the  cavities  of  both  ventricles.  The 
heart  being  suspended  by  hooks  passed  into  three  different  points 
of  the  aorta,  so  as  to  keep  the  vessel  open,  water  is  poured  into 
it.  If  the  valves  are  in  a  perfectly  normal  condition,  they  will 
shut,  completely  closing  the  orifice  against  the  passage  of  the 
liquid.  The  same  experiment  may  be  successfully  tried  with  the 
pulmonary  artery ;  likewise,  with  the  mitral  valve,  it  is  equally 
satisfactory,  but  not  completely  so  with  the  tricuspid.  Through 


°The  normal  heart  may  be  assumed  to  average  for  the  whole  life,  above  puberty, 
about  9  oz.  iii  absolute  weight,  and  8J  oz.  in  bulk,  for  the  male;  aiid  8  oz.  or  a  little 
more  in  weight,  and  7£  oz.  or  a  little  more  in  bulk  for  the  female;  and  to  bear  after 
death,  to  the  weight  of  the  person,  for  the  male,  the  proportion  of  about  1  to  160, 
and  for  the  female,  of  1  to  loO.  [Clendinning,  Croonian,  Lectures  for  1838.] 


380  THORACIC    DISEASES. 

this  latter  valve,  Dr.  King  of  London  contends  that  regurgitation 
even  in  health,  takes  place. 

The  size  of  the  heart  is  modified  by  disease,  and  consequently 
the  physical  signs,  especially  percussion,  are  changed. 

Impulsion. — The  beating  of  the  heart  may  be  felt  by  placing 
the  hand  upon  the  chest,  as  nearly  as  possible  over  the  apex  of 
the  organ.  The  impulsion  is  caused  by  the  striking  of  the  apex 
against  the  ribs,  and  is  generally  supposed  to  arise  from  the  con- 
traction of  the  ventricles,  and  to  be  synchronous  with  the  systole. 
The  truth  of  this  opinion,  however,  is  disputed  by  Dr.  Alfred 
Stille.  On  the  contrary  he  contends  that  the  impulse  of  the  heart 
is  synchronous  with,  and  produced  by  the  diastole  of  the  ventri- 
cle. [Vide  Stille's  Elem.  Gen.  Path.  p.  319.]  The  impulse  is 
given  almost  exclusively  by  the  apex  of  the  heart.  The  sensa- 
tion is,  therefore,  sharp  as  if  caused  by  the  quick  stroke  of  a  small 
hammer.  Exercise  or  nervous  irritability,  increase  its  violence. 
Hypertrophy  also  tends  to  make  the  impulse  greater,  and  by  the 
increase  of  the  bulk  of  the  heart,  extends  the  shock  over  a  much 
greater  surface. 

Great  muscular  debility,  arising  from  asthenic  diseases,  may 
cause  the  impulse  of  an  hypertrophied  heart  to  be  less  powerful 
than  natural.  Its  degree  varies  even  in  health,  according  to  the 
activity  of  the  circulation.  In  those  of  a  phlegmatic  tempera- 
ment, and  the  corpulent,  it  is  often  almost  imperceptible,  while  in 
those  of  a  nervous  temperament,  and  not  fleshy,  it  is  very  strong. 
In  pregnancy,  too,  it  is  subject  to  great  variation.  It  corresponds 
with  the  beating  of  the  arteries,  both  being  dependent  upon  the 
same  cause.  The  radial  pulse,  as  well  as  the  pulse  of  the  larger 
arteries,  is  nearly  synchronous  with  the  beating  of  the  heart,  there 
being  a  very  short  interval  between  them.  The  number  of  pul- 
sations bears  a  relation  to  the  number  of  respirations,  the  former 
being  to  the  latter  as  four  and  a  half  to  one. 

Irregularities  in  the  cardiac  pulsations  are  sometimes  observed 
in  healthy  persons ;  and  this  phenomenon  often  ceases  when  the 
patient  is  laboring  under  an  attack  of  disease,  and  returns  again 
with  the  return  of  health.  A  very  feeble  systolic  contraction  oc- 
curring in  connection  with  a  stronger  one,  may  give  rise  to  inter- 
missions in  the  radial  pulse  when  there  is  none  in  the  heart.  The 


EXAMINATION    OF    THE    HEART.  381 

heart,  however,  is  subject  to  true  intermissions.  Its  impulse  is 
much  changed  by  disease  ; — sometimes  becoming  very  frequent, 
strong  or  weak,  or  frequent  and  irregular.  Hypertrophy  is 
thought  to  augment  its  force  ;  in  some  cases  to  such  a  degree  as 
to  make  the  impulse  seem  like  the  stroke  of  a  hammer  within 
the  chest.  Debility  diminishes  it,  and  the  removal  of  the  heart 
from  the  surface  of  the  thorax  by  pleuritic  effusions  or  by  other 
similar  causes.  The  location  of  the  impulse  is  changed  by  any 
cause  which  can  displace  the  heart. 

Its  character  varies  greatly.  Among  these  common  variations 
is  the  "  short,  sharp,  quick  stroke  of  irritation  which  is  wholly 
different  from  mere  frequency  of  beat ;  the  former  referring  to  the 
individual  pulsations,  the  latter  to  their  succession.  Instead  of  re- 
sulting from  the  striking  of  the  apex  of  the  heart  against  the  ribs, 
the  impulse  is  sometimes  produced  by  the  whole  organ  rising  up, 
as  it  were,  under  the  hand,  and  giving  rise  to  the  sense  of  a  slow 
heavy  motion,  rather  than  of  a  blow.  This  happens  in  dilatation 
and  hypertrophy." 

In  relation  to  the  repetition  of  the  impulse,  it  may  become  so 
frequent  that  it  cannot  be  counted,  even  exceeding  200  strokes  in 
a  minute,  or  may  be  reduced  even  as  low  as  15  or  20,  in  the 
same  length  of  time. 

The  relation  of  the  successive  impulses  to  each  other,  is  liable 
to  excessive  irregularity.  Sometimes  a  stroke  is  now  and  then 
omitted,  either  at  stated  intervals  or  quite  irregularly.  In  such 
cases,  the  pulsation  is  said  to  be  intermittent.  Occasionally,  it  is 
remittent,  one  or  several  strokes  being  more  feeble  than  those 
which  precede  and  follow. 

"  Not  unfrequently  the  rapidity  of  succession  varies  greatly ; 
the  pulsations  being  now  very  short  and  rapid,  almost  running 
into  one  another,  then  again  prolonged,  slow,  and  distinct;  and 
all  these  diversities  may  be  combined  in  the  same  case. 

"  The  double  or  triple  impulse  which  is  sometimes  in  quick 
succession,  may  be  owing  to  as  many  partial  contractions  of  the 
ventricle,  before  the  full  systole  is  accomplished.  Some  have  sup- 
posed that  the  diastole  is  concerned  in  these  irregularities,  as  there 
is  at  that  period  a  sudden  and  apparently  active  swelling  out  of 
the  ventricle,  which  must  make  some  impression  upon  the  parie- 


382  THORACIC    DISEASES. 

tes  of  the  chest.  It  has  been  maintained,  that  there  is  in  health 
a  double  impulse  of  the  heart,  scarcely  sensible  in  its  ordinary 
state,  but  becoming  obvious  in  excitement,  the  first  impulse  being 
dependent  upon  the  systole,  the  second,  much  feebler,  upon  the 
diastole,  and  felt  between  the  second  and  third  ribs."  [Belling- 
ham  and  Sibson,  Lond.  Med.  Gaz.,  March  1850,  p.  445.] 

"Palpitation  sometimes  gives  the  peculiar  thrill  called  fremisse- 
ment  cataire,"  or  the  purring  tremor.  It  is  so  called  because  it 
gives  to  the  hand  when  applied  to  the  thorax,  that  peculiar  sensa- 
tion felt  on  the  chest  of  a  cat  while  purring.  Over  .aneurisms  of 
the  arch  of  the  aorta,  it  is  most  distinctly  perceived  In  valvular 
diseases  it  is  also  felt.  It  may  be  excited  in  nervous  persons  by 
agitation  of  mind.  Unless  the  origin  of  this  symptom  can  be 
traced  to  that  cause,  serious  obstruction  to  the  passage  of  the 
blood  through  the  heart  should  be  considered  as  very  probable. 

1.  PHYSICAL  SIGNS. — Signs  by  Inspection. — Inspection  alone  is  of 
little    value    in    the    diagnosis  of   diseases    of   the    heart.      In 
health   a  slight  movement  over  its  apex  may  be  seen.     In  disease 
sometimes  this  becomes  very  manifest,  being  visible  through  the 
clothing.     This  abnormal  movement  sometimes  extends  to  the 
carotids  and  jugulars,  and  even  the  body  seems  to  be  jarred  by  the 
cardiac  impulse.     But  the  difficulty  is,  to  distinguish  between  the 
causes  of  the  palpitation,  whether  they  arise  from  organic  lesions 
or  from  functional  derangements.     In  cases  of  great  effusion  into 
the  pericardium,  the  external  form  of  the  chest  may  be  somewhat 
altered.     In  the  prascordial  region  a  prominence  is  then  often  seen, 
and  the  left  nipple  is  a  little  more  projecting  than  the  rigit. 

2.  Signs  by  Percussion. — "In   percussing   the   prascordial   re- 
gion, the  best  pleximeter  is  the  fore   finger  of  the  left  hand,  and 
the  best  hammer,  the  first  two  fingers  of  the  right  hand." 

Over  that  part  of  the  thorax  with  which  the  heart  is  in  contact, 
there  is  dullness  on  percussion.  But  as  the  margins  of  the  lungs 
extend  over  a  part  of  the  surface  of  the  heart,  the  percussion  is 
modified,  as  we  recede  from  the  portion  of  the  heart  in  contact 
with  the  chest,  becoming  gradually  less  and  less  dull,  until  the 
normal  resonance  of  the  parts  of  the  chest  over  the  lungs  is  heard. 


EXAMINATION    OF    THE    HEART.  383 

This  change  is  gradual ;  so  that  the  precise  boundary  line  cannot 
be  marked  out  by  the  sounds  of  percussion. 

The  sound  elicited  by  percussion  over  the  praccordial  region, 
varies  according  to  the  position  of  the  body,  the  degree  of  expan- 
sion of  the  chest,  and  the  nature  of  the  diseases  which  affect  ad- 
jacent organs. 

Before  deducing  any  practical  inference,  \ve  should,  therefore, 
take  into  consideration  all  these  circumstances.  The  dullness  is 
increased  by  pronation  of  the  body,  decreased  by  supination. 
Certain  affections  directly  interfere  with  the  indications  on  percus- 
sion. On  the  one  hand,  pleuritic  effusion,  hepatization  of  the 
lung,  tumors  and  enlargement  of  the  left  lobe  of  the  liver  increase 
the  dullness ;  on  the  other,  emphysema,  pneumothorax  and  great 
gastric  flatulence,  decrease  it.  After  making  proper  allowances 
for  all  these  conditions,  percussion  may  be  of  practical  utility  by 
indicating  the  existence  of  hypertrophy  of  the  heart,  cr  of  effu- 
sion into  the  pericardium.  But  how  does  percussion  indicate  the 
existence  of  that  condition  of  the  heart,  or  of  hydropericardium  ? 

"  In  the  natural  state,  the  extent  of  dullness  does  not  exceed  a 
space  of  about  three  inches  in  length,  measured  along  the  ster- 
num, and  about  two  and  a  half  inches  laterally;  that  is,  the  dull- 
ness extends  to  a  short  distance  within  the  nipple,  and  at  about 
the  middle  of  this  space,  just  at  the  left  margin  of  the  sternum, 
it  amounts  in  most  persons  almost  to  perfect  flatness.  The  great- 
est dullness  of  sound  extends  over  a  breadth  of  one  inch  and  a 
half  to  two  inches;  that  is,  over  the  space  which  the  lung  does 
not  overlap ;  so  that  there  are  two  sounds  of  percussion, — one 
nearest  the  sternum  which  is  flat,  and  the  other  more  external, 
which  is  simply  dull.  The  difference  depends  upon  the  percus- 
sion being  made  in  the  latter  case  over  both  the  tissue  of  the 
lungs  and  heart."  [Dr.  Gerhard.] 

Now  if  the  heart  be  enlarged,  or  if  there  is  any  effusion  into 
the  pericardial  cavity,  the  dullness  is  increased  in.  the  direct  pro- 
portion to  the  increased  enlargement.  When  the  dullness  results 
from  hypertrophy  of  the  heart,  it  is  more  rounded  in  shape, — the 
heart  preserving  for  the  most  part  its  original  form — than  when 
it  depends  upon  pericardial  effusion.  In  the  latter  case  the  peri, 
cardium,  though  distended  with  liquid,  still  preserves  its  pyramid- 


384  THORACIC    DISEASES. 

al  form,  the  apex  being  towards  the  upper  part  of  the  chest, 
With  these  preliminary  remarks,  I  now  answer  the  question  above 
proposed.  Hypertrophy  is  indicated  by  the  extension  of  dullness 
over  a  space  larger  than  that  over  which  it  is  perceptible  in  health, 
and  also  by  the  form  of  that  space  which  by  percussion,  and  per- 
haps in  some  cases,  by  inspection  also,  is  proved  to  be  nearly 
round.  Pericardial  effusion  is  indicated  by  the  abnormal  exten- 
sion of  dullness,  and  by  the  pyramidal  form, — apex  upward,  base 
downward, — of  the  space  over  which  the  dullness  is  perceptible. 

3.  Signs  by  Auscultation. — The  action  of  the  heart  gives  rise 
to  sounds  which,  though  not  audible  in  health,  are  so  by  the  ear 
when  applied  to  the  chest.  Some  persons  especially  after  exer- 
cise can  hear  the  beating  of  their  hearts.  In  making  examina- 
tions of  this  organ,  a  stethoscope  should  be  used,  whenever  the 
sound  from  a  very  limited  space  is  desired.  But  the  ear  should  be 
applied  directly  to  the  chest,  whenever  we  wish  to  detect  all  the 
slightest  murmurs.  In  order  to  prevent  the  interference  of  the 
pulmonary  sounds  we  should,  during  a  very  limited  interval,  di- 
rect the  patient  to  stop  respiration.  Dr.  Swett  prefers  the  solid 
stethoscope. 

During  the  examination  the  position  of  the  patient  should  be 
fixed  and  erect,  and  the  prEecordial  region  fully  exposed.  In  fe- 
males a  very  thin  covering  may  be  allowed. 

The  sounds  of  the  heart  may  be  divided  into  normal  and  ab- 
normal. These  in  some  cases  so  blend  together,  as  to  make  it 
difficult  to  detect  the  precise  limit  of  the  former,  and  the  begin- 
ning of  the  latter.  A  full  acquaintance  with  the  former,  must  al- 
ways precede  all  practical  knowledge  of  the  latter.  And  I  cannot 
too  strongly  urge  the  necessity  of  studying  the  physical  condition 
of  the  heart  in  health,  and  of  becoming  familiar  with  all  the  phe- 
nomena of  its  normal  action,  before  beginning  the  study  of  the 
diseased  heart. 

1.  Normal  /Sounds. — The  normal  sounds  of  the  heart  are  two  : 
the  first — synchronous  with  the  impulse,  and,  in  vessels  near  the 
heart,  with  the  pulse — is  duller  and  longer ;  the  second  is  shorter 
and  clearer.  The  latter  immediately  follows  the  former;  and  af- 
ter the  second,  an  interval  of  silence  succeeds.  The  first  sound, 
heard  during  the  systole,  and  hence  often  called  systolic,  is  most 


EXAMINATION    OF    THE     HEART.  385 

distinct  over  that  part  of  the  chest  in  contact  with  the  ventricles. 
The  first  sound  has  been  compared  to  that  produced  by  jerking  a 
cord  as  thick  as  a  swan-quill. 

The  second  sound,  accompanying  the  dilatation  of  the  ventri- 
cles, and  the  contraction  of  the  auricles,  and  hence  sometimes 
called  the  diastolic,  bears  a  close  resemblance  to  that  produced 
"  by  lightly  tapping  with  the  soft  extremity  of  the  finger  of  one 
hand  near  the  ear,  the  knuckle  of  a  bent  finger  of  the  other  hand." 
It  is  heard  most  distinctly  over  the  semilunar  valves;  that  is  "upon 
the  sternum  opposite  to  the  inferior  margin  of  the  third  rib,  and 
thence  for  about  two  inches  upwards,  along  the  diverging  courses 
of  the  aorta  and  pulmonary  artery  respectively,  the  sound  high  up 
the  aorta  proceeding  mainly  from  the  aortic  valves,  and  that  high 
up  the  pulmonary  artery,  being  mainly  from  the  pulmonic." 

The  causes  which  produce  the  first  sound,  have  been  the  sub- 
ject of  discussion,  and  much  theorizing.  Of  their  true  nature, 
Lnennec  was  comparatively  ignorant,  and  Magendie  broached  a 
theory,  not  founded  en  facts,  Mr.  Turner,  of  Edinburgh, 
first  pointed  out  the  true  connection  of  the  sounds  with  the  move- 
ments of  the  heart.  He  maintained  that  the  first  sound  occurred 
during  the  systole,  the  second  during  the  diastole.  Magendie 
maintained,  that  the  first  sound  was  caused  by  the  striking  of  the 
heart  against  the  ribs;  Rona  met,  that  the  two  sounds  were  valv- 
ular, the  first  caused  by  the  tension  of  the  auriculo-ventricular 
valves;  the  second  by  that  of  the  semilunar  or  sigmoid  valves. 
In  relation  to  the  cause  of  the  second  sound,  nearly  all  patholo- 
gists  agree  with  Ronannet  ;  in  relation  to  that  of  the  first  sound, 
authors,  in  general,  agree,  that  it  is  compound,  the  result  of  sever- 
al causes,  among  which  the  principal  is  the  muscular  contraction 
of  the  ventricles. 

That  muscular  contraction  generates  sound,  is  not  a  matter  of 
theory,  but  of  fact.  Dr.  Wolloston  and  many  others,  have  demon- 
strated it.  A  stethoscope,  applied  over  a  contracting  muscle, 
brings  sound  to  the  ear.  By  applying  the  stethoscope  to  the 
heart  of  a  c:ilf,  taken  from  the  body  after  sensation  is  destroyed, 
but  before  the  animal  is  quite  dead,  a  sound  may  be  distinctly 
hoard.  A  cause  of  minor  importance,  is  the  friction  of  the  blcod 
against  the  semilunar  valves, 
49 


386  THORACIC    DISEASES. 

The  other  causes,  adduced  by  authors,  the  tension  of  the  anri- 
culo-ventricular  valves,  the  striking  of  the  heart  against  the  ribs, 
the  auricular  contractions,  may  have  some  tendency  in  conjunc- 
tion with  the  more  important  causes,  to  produce  the  systolic  sound. 

The  second  sound  of  the  heart  is  simple,  and  caused,  as  is  fully 
demonstrated  by  experiments*  by  the  tension  of  the  semiluriar 
valves  of  the  aorta  and  pulmonary  artery  during  the  diastole  of 
the  ventricles. 

"From  the  commencement  of  the  first  sound  until  its  return,  a 
little  less  than  a  second  of  time  is  occupied.  The  duration  of 
the  several  parts  of  the  series  which  constitutes  what  may  be  called 
a  beat,  is  the  rhythm  of  the  heart.  The  beat,  as  described  by 
Laennec,  consists  of  three  periods : — -1.  The  ventricular  systole 
which  occupies  nearly  half  of  the  time  of  a  whole  beat. — (Mr. 
Bryan  says  a  third  only.) — 2.  The  ventricular  diastole  occupies  a 
fourth  ;  or  at  most  a  third. — 3.  The  interval  of  ventricular  repose 
occupies  a  fourth  or  rather  less,  during  the  latter  half  of  which 
the  auricular  systole  takes  place. — [Hope  on  the  Heart.] 

The  first  and  second  sounds  together  are  compared  by  Dr.  Wil- 
liams, to  that  produced  by  the  pronunciation  of  the  monosyllables 
lubb  dup.  Dr.  Bowditch  prefers  this  alteration,  lubb  tuk.  The 
French  have  used  a  very  wrong  sounding  word  tic-tac,  to  repre- 
sent the  double  sound. 

In  duration,  extent  and  loudness,  the  sounds  of  the  heart  differ 
in  health.  It  is  probable  that  the  sounds  produced  by  the  two 
ventricles  are  not  identical;  but  since  the  contraciions  of  both 
sides  of  the  heart  are  synchronous,  nothing  very  definite  in  rela- 
tion to  this  can  be  easily  determined. 

The  quicker,  and  more  energetic  the  ventricular  contractions* 
the  louder  is  the  sound.  The  thickness  of  the  thoracic  parietes 
has  a  modifying  influence.  The  loudness  of  the  ventricular  con- 
tractions, ca3teris  paribus,  is  inversely  proportional  to  the  thickness 
of  the  parietes  of  the  chest. 

By  the  influence  of  mental  emotion,  or  bodily  exertion,  the  in- 
terval of  repose  may  sometimes  be  almost  annihilated.  Hepatiza- 

°In  the  New  York  Journal  of  Medicine  and  Surgery  for  April,  18-10,  is  a  detailed 
account  of  experiments  establishing  the  mechanism  of  the  sounds  of  the  heart. 


EXAMINATION    OF    THE    HEART.  387 

tion  of  the  portions  of  the  lung  contiguous  to,  and  overlaping  the 
heart  may  cause  its  sound  to  extend  over  a  space  unnaturally 
lame. 


ABNORMAL  SOUNDS: — The  sounds  of  the  heart  may  be  altered 
in  character,  or  increased  in  intensity.  The  alteration  may  con- 
sist in  a  slight  abnormal  harshness,  or  the  natural  tone  may  be 
wholly  changed.  The  first  sound  is  most  frequently  altered.  A 
nervous  temperament  may  increase  its  loudness,  or  a  hardening 
in  its  muscular  structure,  conjoined  perhaps  with  slight  ob- 
struction of  the  semilunar  valves.  In  the  former  case,  the  symp- 
tom is  temporary,  in  the  latter  it  is  continuous.  The  phrase  "  in- 
creased loudness,"  and  the  word  "roughness,"  are,  as  used  by  Dr. 
Gerhard,  nearly  identical  in  meaning.  "If  the  roughness  is  in- 
creased," he  continues,  "it  passes  into  the  bellows  or  rasping 
sound.  The  former  of  these  is  less  marked  than  the  latter.  A 
bellows  sound  is  generally  described  as  a  prolonged  and  purring 
sound,  usually  heard  in  the  first  sound  of  the  heart,  and,  there- 
fore, produced  chiefly  by  muscular  contraction,  although  it  may 
also  arise  from  alterations  at  the  auriculo-ventricular  valves,  in 
which  case  it  occurs  during  the  diastole  of  the  heart."  The  term 
bellows  has  been  applied  to  this  sound  on  account  of  its  resem- 
blance to  that  produced  by  blowing  strongly  into  a  bellows.  It 
differs  in  the  degree  of  its  harshness.  In  its  simplest  form  it  is 
"slight,  short  and  breezy,"  the  slightest  prolongation  of  either 
sound  of  the  heart  (bruit  de  souffle,  Fr.].  A  stili  greater  degree 
of  harshness  constitutes  the  pure  bellows  sound  (bruit  de  soufftet, 
Fr.].  Next  is  the  filing  or  ?*aspin<r  sound,  (bruit  de  rape,  Fr.,) 
resembling  the  sound  of  a  rasp  forced  through  soft  wood.  The 
loudest  and  roughest  of  all  is  the  sawing  sound  (bruit  de  scie,  Fr.]. 

Dr.  Pennock  very  properly  suggests,  that  as  sawing  is  a  double 
motion,  the  name  should  be  restricted  to  the  double  murmurs 
produced  by  the  alternate  motion  of  the  heart.  The  bellows 
sound  may  be  short,  or  so  continuous,  as  to  nearly  fill  up  the 
space  between  the  impulses.  This  sound  in  its  pure  form  may 
exist  without  any  organic  change  ;  pressure  upon  a  vessel,  or  any 
pathological  change  causing  sufficient  contraction  to  alter  the  di- 
rection and  velocity  of  the  blood  in  the  arteries,  and  to  cause  it  tp 


388  THORACIC    DISEASES. 

be  reflected  upon  the  sides  of  the  blood  vessels  and  produce 
vibrations,  gives  rise  to  its  development.  By  anaemia,  or  chloro- 
sis, or  excessive  blood-letting,  this  sound  is  liable  to  be  produced. 
A  watery  state  of  the  blood  is  favorable  to  the  production  of 
vibratory  motion.  Its  particles  in  that  condition  move  so  readily 
upon  each  other,  that  a  little  pressure  of  the  stethoscope  upon  an 
artery,  or  even  excitement,  very  often  gives  rise  to  the  bellows 
mur.nur.  "  When  the  bellows  sound  depends  upon  an  hypertro- 
phied  ventricle  urging  the  blood  rapidly  through  a  narrow  or  non- 
dilated  semilunar  valve,  or  driving  it  back  through  a  dilated  auri- 
culo-ventricnlar  opening,  it  is  more  persistent,  more  uniform,  and 
is  less  musical,  but  more  harsh  than  when  it  arises  from  a  mere 
nervous  disorder;  the  same  character  is  found  when  the  sound  is 
heard  during  the  diastole  from  regurgitation  through  the  semi- 
lunar,  or  contraction  of  the  auriculo-ventricular  valves." 

The  variety  of  the  bellows  sound  termed  filing  or  rasping,  is 
produced  by  the  inequalities  of  the  surface  over  which  the  blood 
flows.  These  inequalities  arise  from  depositions  of  lymph,  ex- 
crescences of  various  kinds,  osseous  and  cartilaginous  productions. 
This  sound  indicates  an  organic  disease  in  the  valves.  Another 
cause  of  these  cardiac  sounds  is  some  defect  in  the  valves.  Such 
as  thickening,  dilatation  of  the  orifice,  or  loss  of  substance,  pre- 
venting their  complele  closure,  and  thus  inducing  regurgitation. 
This  variety  of  bellows  murmur  is  scarcely  ever  heard  during 
diastole,  for  its  production  requires  considerable  force  in  the  cur- 
rent of  blood, — more  force  than  regurgitation  through  a  narrow 
orifice  produces.  But  when  the  aorta  is  much  dilated,  the  reflux 
of  the  blood  during  the  ventricular  diastole,  is  almost  as  powerful 
as  its  forward  current  during  systole.  And  the  blood,  passing 
both  forward  and  backward  over  the  irregular  surface  of  the 
diseased  valves,  causes  the  sawing  sound  (bruit  de  scie]  instead  of 
the  rasping.  This  sawing  sound  is  a  diagnostic  sign  of  aneurism 
of  the  aorta. 

The  degree  of  softness  or  loudness  depends  upon  the  force  of 
the  circulation  of  the  blood.  The  systolic  ventricular  murmurs 
are  louder  than  the  diastolic.  The  key  or  tone,  according  to  Dr. 
Hope,  is  higher  or  lower,  according  as  the  sound  is  generated  at 
a  less  or  greater  depth,  by  a  less  or  greater  force,  or  in  a  less  or 


EXAMINATION    OF    THE    HEART.  389 

more  contracted  orifice.  Roughness  of  sound  is  proportionate  to 
the  irregularity  in  the  surface  producing  it.  Dr.  Hope  found  the 
musical  note  most  frequently  an  attendant  on  regurgitation.  By 
changing  the  force  of  the  heart's  action,  the  sounds  are  made 
more  audible,  and  their  character  is  altered.  A  slight  bellows 
murmur  may  be  roughened  by  any  excitement  of  the  heart  which 
increases  the  rapidity  of  the  current.  The  quantity  of  blood,  ac- 
C(  rding  to  Dr.  Williams  modifies  the  murmurs,  increasing  and 
prolonging  them  when  excessive,  and  rendering  them  loud  and 
short  when  defective  and  attended  with  excited  action  of  the 
heart. 

To  ascertain  in  which  of  the  valves  the  murmur  originates 
whether  it  is  dependent  upon  obstruction  caused  by  the  deposi- 
tion of  some  morbid  product  around  the  orifices  of  the  heart,  or 
upon  a  deficiency  or  imperfect  closure  of  the  valves,  is  very  im- 
portant. 

This  desirable  information  as  to  the  valves  affected,  may  in  most 
cases  be  obtained  by  carefully  noticing  the  seat  of  the  murmur, 
as  perceived  by  the  stethoscope. 

"  When  the  sound  is  loudest  on  the  sternum,  immediately  below 
the  insertion  of  the  third  rib,  and  thence  extends  upward  for 
about  two  inches  along  the  course  of  the  great  vessels,  it  may  be 
considered  as  having  its  source  in  the  semilunar  valves.  If  the 
sound  be  perceived  most  distinctly  along  the  course  of  the  ascend- 
ing aorta  upon  the  right,  it  is  probably  seated  in  the  aortic  valves; 
if  along  the  pulmonary  artery  on  the  left,  it  is  in  the  pulmonic 
valves.  When  the  murmur  is  most  distinct  over  that  part  of  the 
chest  on  which  percussion  is  dull,  that  is,  where  the  ventricles  are 
in  contact  with  the  walls,  it  may  be  inferred,  that  it  is  generated, 
either  in  the  mitral  or  tricuspid  valve;  in  the  former,  when  the 
point  of  greatest  loudness  is  a  little  to  the  right  of  the  left  nipple 
and  an  inch  or  so  below  it.  in  the  latter,  when  the  analogous  point 
is  on  or  near  the  sternum  in  the  same  horizontal  line." 

The  solution  of  the  second  question,  whether  the  sound  de- 
pends upon  contraction  or  any  other  obstruction  of  the  valvular 
orifice,  or  whether  upon  an  abnormal  condition  of  the  valves 
themselves,  causing  their  imperfect  closure,  is  mainly  effected  by 
the  observation  of  the  course  of  the  sound,  the  relation  of  the 


390  THORACIC    DISEASES. 

time  of  its  occurrence  to  the  time  at  which  the  ventricular  systole 
and    diastole  lake  place,  and  by  the  character  of  the  sound  itself. 

The  course  of  sound  in  moving  liquids,  as  in  the  atmosphere, 
is  in  that  direction  in  which  the  current  flows.  Confining  my 
remarks,  for  convenience  of  description  to  the  left  side  of  the 
heart — let  us  suppose  that  there  is  contraction  of  the  semilunar 
valves,  or  any  other  obstructing  cause  at  the  orifice  of  the  aorta, 
or  that  the  mitral  valve  is  not  in  a" normal  condition  so  as  to  pro- 
duce a  closure  of  the  auriculo-ventricular  orifice.  In  either  of 
these  physical  conditions,  the  sounds, — in  the  former  case  arising 
from  a  contracted  orifice,  in  the  latter,  from  imperfect  closure. — 
will  be  made  during  the  ventricular  systole.  What  then  does  the 
existence  of  murmurs  during  systole  indicate?  It  may  in  the 
first  place  indicate  contraction  of  the  semilunar  valves,  or  of  the 
orifice  at  which  they  are  located  ;  or  secondly,  regurgitation  through 
the  auriculo-ventricular  opening  into  the  auricle  in  consequence 
of  deficiency  of  the  mitral  valves.  But  how  distinguish  the  one- 
physical  condition  from  the  other?  In  the  former,  the  sound  is 
heard  along  the  course  of  the  large  vessels,  the  aorta  and  pulmon- 
ary artery  ;  in  the  latter  the  sound  does  not  extend  up  those  ves- 
sels. Let  us  now  suppose  an  opposite  physical  condition  of  the 
valves  and  orifices.  Suppose  a  dilatation  of  the  aortic  orifice,  or 
an  insufficiency  in  the  aortic  valves  to  exist,  or  suppose  that  the 
mitral  valve,  instead  of  being  unable  to  produce  complete  clos- 
ure, to  be  so  contracted  as  not  easily  to  open,  or  the  auriculo-ven- 
tricular opening  to  be  obstructed,  what  sounds  will  then  be  pro- 
duced during  the  ventricular  systole?  Evidently  none.  And 
why  ?  Because  the  mitral  valve  very  readily  closes  during  ven- 
tricular systole,  and  the  passage  into  the  aorta  is  not  obstructed. 
What  sounds  occur  during  ventricular  diastole  ?  and  what  do  they 
indicate  ?  As  the  blood  regurgitates  from  the  aorta,  it  produces 
some  variety  of  the  bellows  murmur;  in  case  the  aortic  orifice  is 
dilated,  rough,  and  irregular  it  may  produce  the  sawing — bruit 
de  scie — sound.  If  the  lesion  be  at  the  mitral  valve,  producing 
obstruction  to  the  ingress  of  blood  into  the  ventricle,  the  bellows 
murmur  is  heard  over  the  left  venjricle,  but  it  is  more  obscure  and 
feeble. 

The  same  orifices  may  at  the  same  time  be  contracted,  and  ad- 


EXAMINATION    OF    THE    HEART.  391 

mit  of  regurgitation,  and  more  than  one  orifice  may  be  simultane- 
ously affected.  Hence  the  blowing  sound  may  be  either  single 
or  double  ;  single  when  produced  at  one  orifice,  double  when  at 
two  orifices.  The  orifices  of  the  left  side  of  the  heart  are  much 
more  frequently  affected  with  organic  disease  than  those  of  the 
right.  The  sounds  produced  during  the  systole,  are  louder  than 
those  during  the  diastole. 

"First,  in  relation  to  the  aortic  valve,  if  it  be  obstructed,  the 
^murmur  will  be  heard  during  the  systole,  will  be  rather  loud,  re- 
sembling according  to  Dr.  Hope,  the  whispered  letter  r,  and  will 
follow  the  course  of  the  aorta;  sometimes  even  as  high  as  the 
carotid,  without  being  perceived,  or  but  faintly  so,  over  the  ven- 
tricle. If  the  valve  be  insufficient,  so  as  to  occasion  regurgita- 
tion from  the  aorta,  the  murmur  will  be  heard  during  the  diastole, 
will  be  of  a  lower  key  than  the  preceding,  resembling,  according 
to  Dr.  Hope,  the  word  awe  whispered  in  inspiration,  and  will  be 
most  distinct  over  the  ventricle  into  which  the  regurgitating  cur- 
rent from  the  aorta  is  directed,  though  it  may  also  be  heard  for 
some  distance  up  the  aorta.  Secondly,  in  relation  to  the  mitral 
valve,  obstruction  is  indicated  by  a  diastolic  murmur,  heard  over 
the  left  ventricle,  very  feeble  and  low-toned  in  consequence  of 
the  weakness  of  the  auricular  contraction,  and  the  depth  of  the 
.valve,  and  compared  by  Dr.  Hope  to  the  word  who,  whispered 
feebly.  Insufficiency,  producing  regurgitation,  is  attended  with  a 
louder  sound  of  the  same  character,  is  systolic,  and  may  be  heard 
near  the  apex  of  the  heart,  but  does  not,  like  the  semilnnar  mur- 
mur extend  far  up  the  aorta.  Thirdly,  the  same  rules  apply  to 
the  murmurs  of  the  right  side  of  the  heart;  namely,  those  of  the 
pulmonary  semilunar  valve,  and  the  tricuspid.  They  are  usually 
higher  toned  than  those  of  the  left  side,  because  nearer  the  sur- 
face. They  will  be  sought  for,  of  course,  along  the  direction  of 
the  pulmonary  artery,  or  over  the  right  ventricle.  They  are 
•comparatively  very  rare."  [Wood.] 

The  auriculo-ventricular  sounds,  depending  upon  auricular  con- 
traction and  the  suction  power  of  the  diastolic  ventricles,  some- 
times are  almost  wholly  wanting,  even  where  there  is  considerable 
constriction  of  the  orifices.  The  cause  of  this  is  the  feeble  con- 
traction of  the  auricle.  The  sounds  may  occur  immediately  alter 


THOUACIC    DISEASES. 

the  systole,  during  the  diastole,  at  which  time  the  suction  force 
of  the  expanding  ventricle  operates,  or  after  the  period  of  repose, 
and  just,  before  the  returning  systole.  If  the  murmur  continues 
during  the  ordinary  period  of  silence,  it  indicates  a  deficiency  of 
one  of  the  semiltinar  valves  in  most  cases  that  at  the  commence- 
ment of  the  aorta,  and  consequent  regurgitation. 

To  distinguish  organic  from  functional  affections  of  the  heart, 
is  often  highly  important.  The  pure  bellows  murmur  is  an  at- 
tendant of  both  forms  of  the  disease.  But  the  rough  rasping 
varieties  of  that  sound,  indicate  some  organic  disease  of  the 
valves.  The  sounds  produced  by  regurgitation  are  also  in  most 
cases  consequent  upon  organic  changes. 

By  the  pressure  of  an  enlarged  heart  upon  some  part  of  the 
bronchial  tubes,  a  sound  is  sometimes  produced  simulating  the 
bellows  murmur.  This  sound  is  suspended  by  holding  the  breath 
and  by  this  it  may  be  distinguished  from  the  cardiac  sound. 

1.  PERICARDIAL    SOUNDS. — Friction    sound: — The    motion    of 
the  two  surfaces  of  the   pericardium  upon  each  other,  when  the 
membrane  is  inflamed,  and  covered  by  exudations  of  coagulable 
lymph,  gives  rise  to  a  friction,   or  rubbi'ng  sound,  analogous  to 
that  of  pleurisy  from  which  it   may  be   distinguished  by  its  con- 
tinuance during  suspended  respiration. 

A  great  stiffness  and  roughness  of  the  membrane  give  rise  to  a 
slight  modification  of  this  friction  sound,  called  the  creaking 

O  '  o 

leather  sound,  from  its  supposed  resemblance  to  the  noise  made 
by  new  leather  when  in  motion.  The  friction  sound,  like  the 
bellows  murmur,  may  be  single  or  double.  It  may  accompany 
either  the  diastole  or  systole. 

2.  The  churning  or  washing  sound  is  sometimes  heard  in  case 
of  an  effusion  of  fluid  into  the  pericardial   cavity.     This,   how- 
ever, is  but  rarely  the  case,  and   the  sound  is  of  little  importance. 
In  general  these  pericardiac  sounds  are  more  superficial  than  those 
belonging  to  the  heart  itself. 

Strong  pulsation  of  the  heart,  by  moving  the  air  in  inflamed 
bronchial  tubes,  may  develop  the  mucous  and  sibilant  rales,  and, 
in  large  tuberculous  cavities,  may  produce  metallic  tinkling.  On 
applying  the  ear  to  the  pieecordia,  there  is  sometimes  noticed  with 


EXAMINATION    OF    THE     HEART.  393 

the  impulse,  a  metallic   ring   which    is    in  the  ear  of  the  listener, 
and  not  in  the  heart.     A  violent  and  abrupt  impulse  causes  it. 

Irregularities  in  the  rhythm  of  the  heart : — These  arise  from 
both  organic  and  functional  disease.  The  debility  consequent 
upon  fevers,  or  upon  anasmia  may  cause  this  symptom.  As  a 
diagnostic  sign  it  is  of  little  importance.  Dr.  Gerhard  speaks  of 
an  alteration  of  the  rhythm  that  is  confined  almost  exclusively 
to  organic  valvular  disease,  and  mainly  to  concretions  at  the 
mitral  valve.  The  proportion  as  well  as  the  normal  character  of 
the  sounds,  is  then  nearly  destroyed,  and  there  is  a  confused  churn- 
ing- or  purring  sound.  The  first  and  second  sounds  of  the  heart 
cannot  then  be  distinguished,  the  one  from  the  other.  This  vari- 
ation of  the  rhythm  indicates  the  gravest  lesions  and  is  connected 
with  dilatation  of  the  cavities  and  disease  of  the  valves. 

Vascular  Sounds. — The  movement  of  the  blood  in  the  arter- 
ies when  their  inner  surfaces  are  rough,  or  contracted  by  pressure, 
or  enlarged  by  aneurism,  often  gives  rise  to  sound.  An  anaemic 
condition  of  the  blood  favors  its  production.  Indeed,  so  strong  is 
this  tendency  in  certain  conditions  of  the  circulating  liquid,  that 
the  pressure  of  a  finger  or  stethoscope  upon  an  artery  produces 
it.  It  is  synchronous  with  the  systole  of  the  heart,  and  conse- 
quently, takes  place  during  the  diastole  of  the  arteries.  Some- 
times a  double  murmur  is  produced  in  the  arch  of  the  aorta,  the 
first  corresponding  with  the  systole,  the  second  with  the  diastole 
of  the  heart.  The  diastolic  murmur  is  supposed  to  be  produced 
by  a  regurgitant  movement  of  the  blood  from  the  great  arterial 
branches  in  consequence  of  want  of  due  elasticity  in  the  diseased 
and  dilated  aorta.  (Bellingham,  Lond.  Med.  Gaz.  Sept.  1850,  p. 
399.)  M.  Bean  thinks  that  the  arterial  murmur  is  caused  by  an 
increased  wave  of  blood  thrown  into  the  large  vessels. 

In  the  large  veins,  and  especially  in  the  internal  jugular  of 
anaemic  individuals,  a  peculiar  murmur  is  sometimes  heard  called 
by  M.  Bouillaud  bruit  de  diable,  or  devils  sound,  from  the  name 
of  a  certain  humming  toy,  the  noise  of  which  it  resembles.  It 
is  more  continuous  than  the  bellows  murmur,  is  subject  to  swells 
and  remissions,  and  sometimes  has  a  slight  musical  tone. 
50 


394  THORACIC    DISEASES. 

CHAPTER  II. 

SECTION  I. 
PERICARDITIS. 

Pericarditis,  from  the  Greek  *spixap5iov,  pericardium,  and  itis, 
denoting  inflammation,  is  a  disease  which  has  not  until  recently 
been  well  understood.  It  is  much  more  frequent  than  was  for- 
merly supposed,  and  in  its  termination  is  often  favorable.  Late 
investigations  have  shown  that  pericarditis  is  not  much  more 
severe  than  pleuritis,  and  that  by  rational  symptoms  it  is  not  easily 
known.  The  researches  of  Louis  published  in  the  year  1826, 
have  thrown  much  light  upon  the  obscurity  of  its  diagnosis. 
The  adhesions  of  the  pericardium,  so  often  visible  after  death, 
evince  the  frequency  of  the  disease,  and  also  the  frequency  of  its 
cure. 

But  very  mild  forms  of  pericardial  inflammation  may  exist,  and 
yet  no  anatomical  lesions  be  apparent.  In  a  majority  of  cases  the 
symptoms  are  not  dangerous  or  severe ;  they  are  so  only  in  a 
minority  of  instances.  So  that  it  very  frequently  happens  that 
the  disease  cannot  be  recognized,  except  by  the  physical  signs, 
and  even  these  in  its  mildest  form  are  by  no  means  conclusive. 

PATHOLOGY. — The  pericardium  is  a  serous  membrane,  and  is 
also,  like  the  pleura,  a  shut  sac.  It  is,  therefore,  liable  to  similar 
pathological  changes.  These  in  the  pleural  sac  are  not  necessa- 
rily the  cause  of  immediate  danger,  but  in  the  pericardium  they 
lead  to  more  serious  results.  At  first,  the  natural  secretion  is  some- 
what lessened,  and  a  preternatural  dryness  succeeds.  Coetane- 
ously  with  this  change,  a  slight  deposition  of  lymph  takes  place, 
and  this  increases  until  it  extends  over  the  surface  of  the  pericar- 
dium. In  the  first  stage  the  lymph  is  soft,  not  much  thicker  than 
wrapping  paper.  The  lymph  on  the  heart  causes  a  roughness,  and 
an  appearance  similar  to  a  honey-comb,  or  according  to  Dr.  Wat- 
son, like  the  rough  side  of  a  piece  of  tripe.  The  effusion  of 
serum  sometimes  is  great,  distending  the  pericardium,  and  inter- 
fering with  the  motion  of  the  heart.  Sometimes  the  lymph  pro- 


PERICARDITIS.  395 

daces  adhesion  of  the  heart  to  the  pericardium,  and  thus  effects 
an  obliteration  of  the  sac,  in  which  case  apparent  recovery  takes 
place. 

Sometimes  serum  and  lymph  and  fibrin  are  mingled  together  ; 
arid,  as  in  the  pleura,  so  here  partial  adhesions  are  the  result.  A 
copious  effusion  if  not  reabsorbed,  generally  causes  the  death  of 
the  patient  in  a  few  days.  In  cases  suddenly  fatal,  the  serum  is 
sometimes  clear,  often  turbid,  and  tinged  with  blood,  and  the 
membrane  presents  a  fibrinous  or  albuminous  appearance.  At  the 
commencement  of  the  curative  process  the  serum  is  absorbed,  the 
false  membranes  become  consolidated  into  newly-formed  tissue. 
In  favorable  cases  absorption  is  often  very  rapid,  the  serum  quick- 
ly diminishing  to  such  an  extent  as  not  to  exceed  in  quantity  the 
exudation  of  lymph. 

While  the  effusion  remains  and  the  inflammation  exists,  the 
dyspnoea  and  partial  action  of  the  heart  may  soon  terminate  life. 
If  the  absorption  is  slow,  and  no  adhesion  of  the  pericardium  is 
effected,  the  effusion  gradually  changes  to  the  character  of  pus. 
In  the  majority  of  cases,  however,  pure  pus  is  not  formed,  proba- 
bly because  the  patient  dies  before  the  suppurative  process  is  fully 
established. 

The  redness  of  the  pericardium  is  similar  to  that  induced  by 
inflammation  in  other  serous  membranes.  It  resembles  scarlet 
specks,  and  arborizations  in  the  membrane.  Sometimes  it  is  stel- 
lated in  appearance  ;  sometimes  uniform,  like  a  continuous  stain. 
The  membrane  covered  with  a  fine  vascular  net-work  sometimes 
presents  the  bright  redness  of  arterial  blood. 

Pericarditis  is  rarely  complicated  with  tuberculous  disease.  In 
some  instances,  however,  it  is  met  with,  and  then  the  pathologi- 
cal changes  are  similar  to  those  of  tuberculous  pleuritis. 

DIAGNOSIS. —  General  symptoms. — The  general  symptoms  are 
very  obscure.  The  ordinary  symptoms  of  inflammation  usually 
attend  pericarditis,  a  full  enumeration  of  which  will  be  of  no  ben- 
efit. Those  symptoms  which  more  particularly  point  out  pericar- 
ditis, are  the  following  : — Pain  in  the  region  of  the  heart,  palpita- 
tion, pulsation  and  sometimes  soreness  of  the  carotids,  a  ringing 
in  the  ears  and  vertigo  ;  the  breathing  is  spasmodic,  dyspnoea  con- 


396  THORACIC    DISEASES. 

siderable;  pulse  jarring,  jerking  and  peculiar.  The  pulse  accord- 
ing to  Dr.  Hope,  is  the  most  sure  of  all  the  general  symptoms  to 
guide  the  physician  to  a  correct  diagnosis.  Whenever  it  is  feeble, 
faltering,  intermittent,  unequal,  this  sign,  especially  if  continued, 
affords  evidence  of  the  strongest  description. 

Fever  is  almost  always  present,  unless  the  case  is  very  mild. 
Pain  is  a  very  uncertain  symptom.  It  may  be  a  feeling  of  slight 
uneasiness,  not  causing  any  decided  suffering,  or  very  acute  shoot- 
ing from  the  praecordia  to  the  back  between  the  shoulders,  and 
extending  down  the  left  arm,  sometimes  as  low  as  the  elbow  or 
even  the  wrist.  As  in  pleuritis,  so  in  this  disease,  the  acute  pain 
is  most  severe  in  the  first  stage  of  the  disease,  diminishing  in  in- 
tensity as  the  effusion  increases. 

Dyspna&a  is  moderate  in  simple  cases,  but  more  severe  in  those 
complicated  with  inflammation  of  the  internal  membrane  of  the 
heart,  or  with  pneumonitis  and  pleuritis. 

Cough,  in  pericarditis,  a  disease  involving  the  lungs  indirectly, 
is  not  a  prominent  symptom  unless  in  complicated  cases. 

PHYSICAL  SIGNS. — In  mild  cases,  and  in  the  early  stage,  these 
are  often  insufficient  for  accurate  diagnosis. 

1.  Signs  by  Inspection, — The   distension   of  the   pericardium, 
gives  rise  to  an  abnormal  fullness  of  the  praecordial  region.     This 
assumes  a  pyramidal  form,  and  extends  beyond  the  ordinary  limits 
of  the  praecordia.     Sometimes   there  is  a   prominence  of  the  left 
breast,  when  compared  with  the  right,  and   the   position  of  the 
left  nipple  is  usually  higher  than  the  right.     A  stronger  impulse  is 
felt  over  the  region  of  the   heart  than  is  usual.     The  intercostal 
spaces  are  often   bulging  and  tender  to   the  touch.     The   upper 
portion  of  the  epigastric  region  is  likewise  sensitive  to  pressure. 

2.  Percussion. — The  distension  of  the  pericardium  with  fluid, 
causes  dullness  on  percussion.     The  impulse  becomes  undulatory, 
arid  not  exactly  coincident  with  the  systole  ;  because  the  heart 
must  displace  the  fluid,  between  itself  and  the  thoracic  walls  before 
it  can  impinge  upon  the  parietes  of  the  thorax. 

3.  Auscultation. — Copious  effusion  impedes  the  free  motion  of 
the  heart,  and  by  preventing  its  contact  with  the  th'orax,  prevents 
the   conveyance  of  the  sounds  to  the  ear.     They,  therefore,  be- 


PERICARDITIS.  397 

come  indistinct,  the  degree  of  the  feebleness  depending  upon  the 
amount  of  effusion.  On  account  of  the  increased  velocity  of  the 
blood,  and  the  abrupt  jerking  contractions  of  the  ventricles,  the 
first  sound  becomes  even  louder  than  natural,  but  somewhat 
changed  and  altered  to  a  bellows  or  rasping  character.  But  in- 
flammation confined  wholly  to  the  pericardium,  seldom  gives  rise 
to  those  sounds,  and  when  it  does  so,  the  cause  is  more  in  the  ex- 
cited circulation  which  it  induces  than  in  the  actual  lesion  of  the 
endocardium. 

In  certain  stages  of  pericarditis  there  is  a  friction  sound,  the 
conditions  for  the  production  of  which  are  similar  to  those  of 
pleuritis.  Accordingly,  we  hear  this  sound  when  there  is  an 
effusion  of  lymph,  roughening  the  membrane,  and  but  little  se- 
rum. 

This  condition  usually  occurs  at  the  beginning  of  the  disease, 
and,  consequently,  then  this  sound  compared  by  some  authors  to 
that  produced  by  the  bending  of  new  leather,  (  bruit  dc  cuir 
nenf )  the  creaking  leather  sound,  is  most  frequent.  After  the 
fluid  is  absorbed  and  the  roughened  membranes  are  in  contact, 
this  is  again  produced.  It  is  then  an  indication  of  returning 
health  ;  because  it  shows  that  absorption  has  taken  away  the  ab- 
normal quantity  of  fluid,  and  that  the  membranes  again  approach 
to  jutaxposition.  This  friction  sound  is  sometimes  more  rough  ; 
and  then  it  receives  the  epithets  grating  or  rasping.  These 
sounds  may  be  double,  occurring  at  every  contraction  of  the  heart, 
and  sometimes  according  to  Dr.  Pennock  they  become  treble  or 
even  quadruple. 

There  is  a  degree  of  danger  of  confounding  these  friction 
sounds  with  the  valvular  murmurs  which  indicate  the  existence 
endocarditis.  But  the  former  are  more  superficial  than  the  latter, 
are  rougher,  especially  when  coincident  with  the  second  sound  of 
the  heart, — are  more  apt  to  change  their  position  with  a  change 
of  posture,  and  are  inaudible  at  the  distance  of  two  or  more  inch- 
es up  the  pulmonary  artery  or  aorta,  where  the  murmurs  of  the 
sigmoid  valves  in  endocardial  inflammation,  are  heard  distinctly, 
and  are  not  like  the  murmurs  of  the  auriculo-ventricular  valves, 
uniformly  loudest  near  the  apex  of  the  heart. 

With  the  friction  sound  there  is  often  a  vibratory  tremor  felt  by 


398 


THORACIC    DISEASES. 


the  hand  placed  over  the  heart.  Whether  this  friction  sound  is 
caused  by  the  rubbing  together  of  the  pleura,  or  of  the  surfaces 
of  the  pericardium  can  be  determined  by  the  suppression  of  res- 
piration, which,  in  pleuritis  arrests  the  sound,  in  pericarditis  it 
does  not. 

When  there  is  effusion  in  the  pericardial  cavity  the  washing  or 
churning  sound  is  sometimes  heard.  This  symptom,  however,  is 
of  minor  importance. 

The  friction  sounds  may  in  some  instances  be  confounded 
with  the  mucous  rales  of  bronchitis,  but  the  latter  cease  when 
respiration  is  suspended,  while  the  former  remain  unaffected. 

Pericarditis,  carditis  and  endocarditis  often  exist,  together. — 
When  this  is  the  case  the  friction  sounds  and  the  valvular  mur- 
murs will  be  produced. 

Course  and  termination  of  the  sthenicfonn  of  pericarditis. — In 
violent  cases  the  disease  quickly  runs  its  course,  and,  in  less  than 
forty-eight  hours  may  terminate  fatally.  In  mild  cases,  it  some- 
times continues  for  weeks,  not  entirely  losing  its  acute  character. 
Ordinarily  the  disease  yields  in  the  course  of  a  week  or  ten  days. 
Under  the  influence  of  energetic  and  appropriate  treatment  it  may 
terminate  in  less  time.  In  case  it  ends  in  recovery,  the  fluid  is 
absorbed,  the  friction  sounds  return,  respiration  and  the  impulse  of 
the  heart  become  more  audible,  adhesion  is  effected  and  the  cure 
.completed.  If  unfavorably,  general  weakness,  oppression,  and  the 
symptoms  of  imperfect  circulation  are  the  premonitors  of  death. 


SECTION  II. 
CHRONIC    PERICARDITIS. 

When  the  disease  assumes  an  asthenic  form,  or  when  the  vio- 
lence of  the  acute  attack  subsides,  leaving  a  low  degree  of  con- 
tinuous inflammation,  the  term  chronic  is  usually  applied.  The 
difference  between  this  and  the  acute  form  is  one  of  degree 
rather  than  of  kind.  The  symptoms  of  chronic  pericarditis,  like 
those  of  the  acute  form,  are  somewhat  variable  and  obscure. 
And  yet  there  are  certain  points  of  difference,  that  it  may  be  well 
to  notice.  Not  unfrequently  there  is  no  pain,  and  the  patient  com- 


PERICARDITIS.  399 

plains  only  of  a  sense  of  weight,  oppression,  or  stricture  in  the 
prascordia.  A  little  dyspnoea  may  be  present.  The  pulse  is  some- 
what frequent,  irregular  and  feeble,  rather  than  strong  and  active. 
The  countenance  is  of  a  livid  hue,  or  pale  and  puffy  ;  there  is  an 
absence  of  the  respiratory  sounds,  they  being  distant  and  obscure, 
dullness  on  percussion  and  enlargement  of  the  prsecordial  region. 
The  impulse  too  is  less  than  in  the  acute  variety  of  pericarditis. 

This  may  be  confounded  with  dilatation  of  the  heart,  and  hy- 
dropericardium.  But  dilatation  is  usually  attended  with  a  pecu- 
liar impulse,  and  increased  loudness  of  the  cardiac  sounds,  but 
never  with  the  friction  sounds.  Hydropericardium  is  without 
local  pain  or  febrile  action,  and  is  usually  attended  with  anasarca 
and  with  dropsy  of  other  parts  of  the  system. 

The  causes  of  chronic  pericarditis  are  found  for  the  most  part 
in  a  depraved  condition  of  the  blood,  in  general  debility,  and  in 
a  tuberculous  cachexia. 

Causes  of  Acute  Pericarditis. — The  slighter  cases  are  caused 
by  exposure  to  cold  and  dampness.  The  retrocession  of  eruptions, 
suppression  of  hemorrhages,  or  other  morbid  discharges,  may  give 
rise  to  this  disease.  Scarlatina,  erysipelas  and  granular  disease  of 
the  kidney,  are  sometimes  connected  with  its  production.  Inflam- 
mation of  the  lungs,  and  its  investing  membrane  is  also  influen- 
tial in  exciting  pericardial  disease.  Out  of  265  cases  of  pnen- 
monitis,  pleuritis,  and  pleuro-pueumonitis,  there  were  according  to 
Dr.  Ormerod,  33  cases  of  pericarditis.  But  of  all  the  causes 
acute  articular  rheumatism  is  the  most  frequent.  By  the  highest 
authority  it  is  asserted  that  at  least  one-half  of  the  cases  of 
acute  rheumatism  are  accompanied  with  pericarditis  or  endocarditis, 
or  with  both  together.  Out  of  161  cases  of  acute  rheumatism, 
according  to  Dr.  Ormerod,  there  were  61  cases  of  pericarditis. 
[Half- Yearly  Abstract  Mod.  Sci.  No.  17,  1853,  p.  78.] 

The  age  has  some  influence  upon  its  production.  Persons  be- 
tween eight  and  thirty-five,  are  more  subject  to  this  disease  than 
others. 

DIAGNOSIS. — Pericarditis  may  be  confounded  with  pleuritis, 
pneumonitis,  endocarditis  and  pleurodynia.  From  pleuritis  it 
may  be  distinguished  by  the  confinement  of  the  dullness  to  the 


400 


THORACIC    DISEASES. 


prascordial  region,  by  the  absence  of  egophony,  by  the  friction 
sounds  which  accompany  the  movement  of  the  heart,  and  con- 
tinue while  respiration  is  suspended. 

Pneumonitis  gives  rise  to  no  projection  of  the  chest,  no  friction 
sounds,  nor  to  the  altered  condition  of  cardiac  sounds.  And  be- 
sides it  presents  its  own  symptoms,  the  crepitant  rale,  bronchial 
respiration  and  resonance,  the  rusty  and  viscid  sputum. 

Pleurodynia  has  but  few  symptoms  in  common  with  pericar- 
ditis, and  these  are  acute  pain  in  the  side,  difficulty  of  breathing, 
tenderness  on  pressure  between  the  ribs.  This  has  no  physical 
signs  which  in  any  degree  are  characteristic  of  pericarditis,  and 
therefore,  them  is  no  necessity  for  mistaking  this  affection  for  per- 
icardial  inflammation. 

Endocarditis  affecting  the  internal  membrane  of  the  heart  it- 
self, must  necessarily  produce  many  symptoms  in  common  with 
pericarditis.  And  yet  when  inflammation  is  wholly  confined  to  the 
external  membrane  of  the  heart,  there  are  signs  which  with  much 
certainty  distinguish  it  from  disease  confined  wholly  to  the  inter- 
nal. 'These  are  the  dullness  on  percussion  over  the  preecordia, 
the  prominence  of  the  chest,  the  faintness  or  distance  of  the  car- 
diac sounds,  and  absence  of  the  respiratory.  And  besides,  there 
are  the  friction  sounds  superficial  and  often  distinct,  and  the  purr- 
ing tremor,  and  the  absence  of  those  valvular  murmurs  which 
arise  from  morbid  changes  of  the  internal  membrane. 

PROGNOSIS. — In  general  the  prognosis  is  favdrable.  In  its  mild 
form  it  yields  to  the  influence  of  remedies  very  readily.  Not  un- 
frequently  without  any  interference  from  medicine,  it  spontane- 
ously terminates  in  health.  The  treatment  adopted  by  the  phy- 
sician has  much  to  do  in  determining  the  nature  of  the  prognosis. 
If  it  be  that  of  M.  Bouillaud — free  and  repeated  venesection — the 
physician  will  seldom  lose  credit  by  presaging  a  fatal  termination. 
Drs.  Latham,  Todd  and  Watson,  seldom  employ  the  lancet,  and 
their  prognosis  has  been  more  favorable  than  that  of  others  In 
its  simple  form  in  all  probability  Dr.  Wood  remarks,  "it  would 
subside  spontaneously,  like  so  many  other  inflammations  under  a 
proper  regimen,  as  relates  to  diet  and  rest."  The  simple  cases 
may  in  a  majority  of  instances  be  considered  as  curable  by  ap- 


PERICARDITIS.  401 

propriate  remedies.  Like  all  other  inflammatory  diseases  of  serous 
membranes,  it  often  even  in  its  most  uncomplicated  form,  requires 
a  vigorous  application  of  anti-inflammatory  agents  in  order  to 
ward  off  its  speedy  termination  in  death.  When  it  occurs  in  per- 
sons worn  out  by  previous  disease,  or  when  it  supervenes  upon 
organic  affections  of  the  heart  or  other  organs,  its  termination  is 
generally  unfavorable. 

If  the  friction  sound  ceases  after  a  short  existence,  and  coinci- 
dent with  its  cessation,  we  find  decreasing  dullness  in  the  pra?cor- 
dial  region,  increasing  steadiness  in  the  action  of  the  heart,  and 
clearness  and  loudness  of  its  sounds,  the  prognosis  must  be  favor- 
able. If  the  friction  sound  continues  for  considerable  time,  it  in- 
dicates that  the  amount  of  effused  serum  is  not  great,  and  that  the 

<^/  7 

effused  lymph  is  of  so  low  a  degree  of  vitality,  as  to  prevent  a 
speedy  adhesion.  If,  on  the  contrary,  the  friction  sound  disap- 
pears early  in  the  disease,  and  the  dullness  increases,  and  the  im- 
pulse and  sounds  of  the  heart  become  weaker,  and  almost  invari- 
able, if  the  pulse  at  the  same  time  is  fluctuating  and  intermittent, 
then  the  prognosis  is  doubtful.  Great  dyspnoea,  syncope,  the  sar- 
donic expression  of  countenance,  severe  darting  pain  through  the 
prsecordia  to  the  shoulder, — all  these,  when  occurring  at  the  same 
time,  indicate  speedy  dissolution. 

There  are  two  modes  of  termination,  one  adhesion,  the  other 
resolution.  The  termination  by  adhesion  has  been  considered  by 
some  authors,  among  whom  was  Dr.  Hope,  as  only  a  temporary 
cure.  This  is  probably  true  in  relation  to  those  cases  in  which 
the  deposition  of  lymph  is  great,  resulting  in  the  formation  of  a 
stiff,  fibrinous  envelope.  But  this  view  of  the  effect  of  adhesion 
is  not  always  correct,  according  to  the  best  and  most  reliable  au- 
thority. The  effect  of  pericardia!  adhesion  is  similar  to  that  of 
pleuritic,  and  as  the  latter  is  often  present  without  materially  in- 
terfering with  the  functions  of  the  lungs,  so  the  former  may  exist 
without  producing  organic  lesion  of  the  heart. 

TREATMENT. — This  disease  being  an  inflammation  of  a  serous 
membrane,  requires  the  general  course  of  treatment  adapted  to  the 
cure  of  pleuritis,  or  peritonitis. 

A  proper  discrimination  should  be  made  as  to  the  character  of 
51 


402  THORACIC    DISEASES. 

%i 

the  disease,  whether  sthenic  or  asthenic,  and  also  as  to  the  causes 
of  the  disease,  whether  proceeding  from  rheumatism,  affections  of 
the  lungs  or  of  the  kidneys.  Attention  should  also  be  directed  to 
the  stage  of  the  disease. 

The  first  object  is  to  remove  those  exciting  causes, — whatever 
they  are, — which  immediately  produce  the  inflammation  ;  secondly, 
to  arrest  the  progress  of  the  local  disease  ;  and  thirdly,  to  obviate 
the  ill  effects  arising  from  the  products  of  the  pericardial  inflam- 
mation. Among  the  exciting  'causes,  cold  and  dampness  are  fre- 
quently found.  To  overcome  their  bad  effects,  a  warm  or  vapor 
bath  followed  by  brisk  rubbing,  will  very  materially  aid  in  arrest- 
ing the  inflammation  in  its  nascent  state.  Whenever,  therefore, 
any  symptoms  of  pericarditis  supervene  after  a  sudden  check  to 
perspiration,  the  first  object  should  be  by  .baths  or  by  diaphoret- 
ics, to  restore  capillary  action.  For  the  purpose  of  promoting  cu- 
taneous exhalation,  and  producing  a  sedative  effect  upon  the  gen- 
eral system,  the  extract  of  lobelia  pill,  should  be  given  in  alterna- 
tion with  some  diaphoretic  compound. 

If  the  cardiac  symptoms  arise  coetaneously  with  acute  articular 
rheumatism,  and  are  evidently  produced  by  that  acid  state  of  the 
blood  which  is  so  characteristic  of  rheumatic  affections,  the  rem- 
edies should  be  directed  to  the  removal  of  that  condition  of  the 
circulating  fluid  in  which  the  pericarditis  has  its  origin.  In  such 
cases  nothing  will  prove  so  serviceable  as  a  vapor  bath,  followed 
by  an  emetic  given  in  combination  with  alkalies,  and  then  the 
.administration  of  leptandria  and  podophyllin,  in  combination  with 
neutralizing  mixture. 

The  above  course  of  treatment  when  adopted  before  the  dis- 
ease has  far  progressed,  will  in  most  cases  arrest  its  further  pro- 
gress. But  if  the  fever  is  of  a  sthenic  form,  the  pain  in  the  pras- 
cordia  severe,  and  the  friction  sounds  are  audible,  and  at  the  same 
time  the  patient  is  somewhat  plethoric,  no  time  should  be  lost  in 
the  vigorous  application  of  anti- inflammatory  agents.  Means 
should  be  immediately  used  to  produce  general  relaxation  of  the 
system.  For  this  purpose,  administer  once  in  fifteen  minutes  a 
pill  containing  from  two  to  six  grains  of  the  extract,  or  an  equiv- 
alent quantity  in  some  other  form  of  lobelia,  until  the  muscular 
system  becomes  relaxed,  the  pulse  reduced  in  frequency  and  the 


PERICARDITIS.  403 

heat  of  the  surface  subsides.  A  strong  sinapism  should  be  placed 
over  the  praecordia,  or  a  fomentation  of  bitter  herbs.  After  the 
constitutional  effects — that  is  the  general  relaxation  and  perspira- 
tion.— are  produced  the  remedy  may  be  carried  to  such  an  extent 
as  to  produce  emesis,  after  which  an  interval  of  rest  should  be  al- 
lowed. Subsequent  to  the  production  of  emesis,  some  diapho- 
retic powder  or  anti-febrile  remedy  should  be  used. 

The  surface  should  be  bathed  in  an  alkaline  solution,  whenever 
it  is  dry  and  hot.  In  case  there  is  costiveness,  a  mild  cathartic 
composed  of  the  following  articles  may  be  administered. 

R         Leptandria3  virginicas  gr.  xx., 

Sennaa  gr.  xx., 

Podophyllias  gr.  i. 

Misce. 

Take  in  sirup  or  molasses. 

This  course  of  treatment  vigorously  applied  at  the  beginning  of 
the  disease,  will  usually  cause  it  to  terminate  in  resolution.  If, 
however,  the  friction  sounds  diminish,  and  dullness  on  percus- 
sion increase  over  the  prascordia,  and  the  general  symptoms  do 
not  abate  but  rather  increase,  effusion  has  probably  taken  place, 
and  means  should  then  be  used  to  remove  the  fluid  in  the  peri- 
cardium. The  third  indication,  the  removal  of  the  products  of 
inflammation  should  then,  if  possible,  be  accomplished.  In  com- 
bination with  the  anti-inflammatory  agents,  diuretics  should  then 
be  used.  This  compound  produces  diaphoresis,  and  diuresis,  and 
may  in  some  cases  be  used  with  profit : — 

R         Tinctune  lobelias  5ii., 

Tincture  digitalis  5  i. 

Misce. 
Dose — from  twenty  to  thirty  drops  once  in  8  hours. 

By  high  authority,  the  following  course  of  treatment  is  recom- 
mended. In  the  first  place,  administer  medicines  to  promote  ab- 
sorption into  the  veins,  such  as  the  iodide  of  potassium,  and  in 
about  twenty-four  hours  after  produce  its  removal  by  free  diapho- 
resis, catharsis  or  diuresis.  In  the  iodide  of  potassium,  I  have  but 


404 


THORACIC    DISEASES. 


little  faith.  A  vapor  bath,  with  the  internal  use  of  diaphoretic 
doses  of  lobelia,  and  a  free  administration  of  vegetable  diuretics, 
will  excite  absorption  secondarily  by  the  removal  of  the  normal 
quantity  of  serum  from  the  blood  vessels.  When  the  case  is  of 
a  sthenic  form,  the  administration  of  the  following  pill  to  produce 
a  hydragogue  effect,  will  prove  efficacious : — 

R         Irisiae  gr.  x., 

Podophyllias  gr.  x., 

Capsici  gr.  xx., 

Potass,  bicarbonatis  9ii. 

Misce. 

Divide  into  two  grain  pills  and  give  from  one  to  two  at  night 
and  in  the  morning,  if  a  free  hydragogue  effect  is  desired.  The 
diuretics  in  the  chapter  on  pleuritis  are  equally  applicable  in  peri- 
carditis with  effusion. 

In  asthenic  cases  and  those  of  a  chronic  character,  the  spirit- 
vapor  bath,  should  not  be  so  long  continued  as  to  cause  much 
prostration.  The  object  is  to  produce  a  fullness  of  the  cutaneous 
capillaries,  and  to  add  tone  to  the  general  system.  More  nour- 
ishment and  mild  stimulants  should  then  be  given  than  in  the  more 
sthenic  forms  of  the  disease.  For  a  counter  irritant  the  plaster 
and  poultice  recommended  in  the  article  on  pleuritis  may  be  us- 
ed. A  plaster  applied  over  the  spine,  alternately  with  one  over 
the  prascordia  is  often  useful.  It  should  be  continued  until  the 
podophyllum  or  lin,  on  its  surface,  has  time  to  produce  its  irritant 
and  vesicating  effects. 

As  soon  as  there  is  a  return  of  the  friction  sounds,  and  an  in- 
crease in  the  loudness  of  the  beatings  of  the  heart,  together  with 
the  general  symptoms  of  amendment,  tonics  should  be  used  in 
combination  with  nourishing,  yet  easily  digestible  diet.  More  es- 
pecially are  these  means  necessary,  when  the  blood  is  in  an  anas- 
mic  state,  and  when  oedema  of  many  parts  of  the  system  is 
manifest.  In  such  a  condition  of  the  blood,  the  preparations  of 
iron  administered  in  combination  with  hydrastis  and  pupulus  will 
be  effectual  means  of  cure.  As  a  general  stimulant  and  diapho- 
retic and  laxative  the  following  pills  are  excellent : — 


ENDOCARDITIS.  405 

R.        Lob.  Sem.  pulveris  §  i., 

Capsici  §  i-, 

Sodas  bitartratis  §  i., 

Extract!  bovis  fellis  q.  s. 
Ft.  gr.  iv.  pil. 

DOSE — from  one  to  three,  three  times  per  day.  This  is  a  remedy 
which  can  be  used  instead  of  an  emetic.  When  the  pills  are  contin- 
ued a  number  of  days  they  almost  always  restore  the  equilibrium 
of  the  circulation,  and  thus  tend  to  prevent  those  congestions 
which  always  precede  inflammation  ;  and  while  they  do  so  they 
increase  the  digestive  functions,  and  secure  to  the  patient  the  for- 
mation of  the  elements  of  the  blood.  In  case  no  laxative  effect 
is  indicated,  the  last  article  in  the  formula  should  be  left  out  and 
the  gum  acacia  used  in  its  stead  to  form  a  pill  mass. 

Patients  laboring  under  this  disease  should  avoid  all  kinds  of 
excitement,  whether  mental  or  corporeal,  and  live  upon  such  food 
as  is  nutritious  but  not  exciting.  ' 


CHAPTER  III. 
ENDOCARDITIS. 

The  term  endocarditis  from  the  Greek  word  svSm  within 
x«p')ia  heart,  and  itis,  inflammation,  is  applied  to  inflammation 
of  the  endocardium,  or  the  internal  membrane  of  the  heart.  This 
disease  gives  rise  to  alterations  in  the  cardiac  valves,  and  in  its 
muscular  structure.  In  its  secondary  effects,  exist  the  dangerous 
results  of  the  disease,  rather  than  in  its  primary.  This  is  known 
from  two  sources.  In  individuals  previously  healthy  endocardial 
inflammation  very  often  terminates  in  structural  changes  of  the 
valves.  And  secondly,  in  those  who  have  died  of  valvular  disease 
traces  of  previous  inflammation  almost  always  exist.  This  opinion 
however,  is  not  in  strict  agreement  with  that  of  Dr.  Fuller.  He 
contends  that  the  depositions  on  the  valves  are  due  to  the  pres- 
ence of  an  unusual  quantity  of  fibrin  in  the  blood,  and  to  the 
weak  state  of  solution  in  which  it  is  held  in  consequence  of  that 
abnormal  degree  of  acidity  in  the  system,  which  so  often  accom- 


406  THORACIC    DISEASES. 

% 

panies  or  precedes  endocarditis.  The  inflammation  may  make  ac- 
cording to  his  view,  the  liability  of  deposition  greater,  inasmuch 
as  it  tends  to  roughen  the  surface  of  the  valves,  and  in  this  way 
tends  to  favor  the  adhesion  of  the  particles  of  fibrin  passing  along 
in  the  current  of  circulation.  From  these  opposite  opinions  we  may 
safely  conclude  that  the  structural  changes  are  the  result  of  more 
than  one  cause,  and  that  medical  investigation  has  not  yet  accu- 
rately determined  just  how  much  of  the  result  is  due  to  the  in- 
fluence of  the  one,  or  to  that  of  the  other.  That  same  condition 
of  the  blood  which  favors  the  deposition  also  favors  the  production 
of  inflammation.  So  that  from  one  cause, — a  general  one  existing 
in  the  blood, — more  than  one  injurious  effect  arises. 

PATHOLOGY. -^-Inflammation  of  the  endocardium  cannot  on  account 
of  the  motion  of  the  circulating  fluid  leave  behind  all  those  prod- 
ucts which  are  formed  in  the  pericardium.  To  the  membrane  it- 
self we  must,  therefore,  look  for  the  changes  resulting  from  this 
disease.  On  examination  we  find  its  natural  transparency  replac- 
ed by  whiteness  and  opacity  ;  fibrin  may  be  deposited  upon  it 
forming  beaded  or  wart-like  fleshy  excrescences,  and  lymph  may 
be  effused  either  beneath  or  on  its  surface  giving  rise  to  thicken- 
ing, rigidity,  and  puckering.  In  some  cases  ulceration  ensues, 
giving  rise  to  irregular  vegetations,  partly  consisting  of  lymph 
partly  of  calcareous  matter,  producing  perforations  of  the  valves 
or  a  ragged  state  of  their  edges,  or  extending  to  the  chordae  tendi- 
nese,and  eating  through  them  and  sometimes  causing  a  perforation 
of  the  septum  ventriculorum. 

These  morbid  changes  are  found  in  the  different  chambers  of 
the  heart  ;  but  in  the  majority  of  instances  they  are  located  on 
the  valvular  apparatus,  or  in  its  immediate  neighborhood.  The 
aorta  and  mitral  valves  are  peculiarly  liable  to  these  changes.  The 
right  cavities,  however,  with  their  tricuspid  and  pulmonary  semi- 
lunar  valves,  are  sometimes,  though  rarely,  affected. 

The  fibrinous  vegetations  vary  greatly  in  their  appearance. 
They  are  often  very  numerous,  and  vary  in  size  from  a  pin's  head 
to  a  millet  seed.  They  are  at  one  time  isolated,  and  at  others 
partially  confluent;  and  when  several  spring  from  a  common  base, 
they  may  form  a  mass  of  considerable  size.  Sometimes  when 


ENDOCARDITIS.  407 

fibrinous  accretion  has  taken  place  rapidly,  its  form  and  appe^r- 
ance  is  changed,  which  in  other  states  of  the  system  might  have  re- 
sulted in  the  deposition  of  small  warty  grannies  along  the  edges 
of  contact  of  the  valves.  In  the  sigmoid  they  are  arranged  in  a  dou- 
ble crescentic  form  ;  but  when  their  growth  is  more  luxuriant,  they 
are  more  widely  distributed  over  the  endocardia!  membrane. 

The  surface  of  the  valves  is  thickly  studded  with  them.  On 
the  edges  of  contact  of  the  valves,  they  form  festoons  or  fringes  ; 
the  chcrda?,  tendineas  of  the  mitral  valves  are  sometimes  load- 
ed with  an  abundant  crop  of  them  ;  and  occasionally  in  different 
parts  of  the  heart,  they  are  scattered  profusely  over  the  entire  sur- 
face of  the  lining  membrane.  The  cases  in  which  the  last  form  of 
vegetations  occurs,  are  just  those  in  which  the  accretions  manifest 
a  strong  tendency  to  decay,  and  in  which  arise  those  formidable 
erosions  and  ulcerations  to  which  allusion  has  already  been  made. 

In  color  and  consistency  these  accretions  greatly  vary.  They 
are  sometimes  gray  and  friable,  sometimes  of  a  pink  or  reddish 
color,  soft  and  easily  broken  down,  and  can  readily  be  detached 
from  the  smooth  surface  of  the  membrane  on  which  they  are  de- 
posited. At  others  they  are  less  colored  and  of  a  much  firmer 
consistency,  but  still  admit  of  being  separated  from  the  membrane  ; 
whilst  in  another  class  of  cases  they  become  perfectly  colorless,  and 
so  firmly  adherent,  that  they  can  be  removed  only  by  tearing  the 
membrane  to  which  they  are  attached.  At  a  still  later  period 
these  warty  growths  or  bead-like  accretions  cease  in  many  cases 
to  exist  as  such  upon  the  valves.  They  become  by  degrees  more 
firmly  agglutinated  to  the  endocardial  membrane,  and  incorporated 
with  the  structure  of  the  valve;  and  merging  gradually  into  one 
another,  until  the  divisions  between  the  several  granules  are  effa- 
ced, they  are  ultimately  replaced  by  a  laminated  ridge  of  fibrin. 
This  is  marked  at  first  by  serratures,  corresponding  to  the  divis- 
ions between  the  original  granules,  but  after  a  time  it  also  loses 
all  traces  of  its  origin  or  mode  of  formation,  and  becomes  smooth 
and  polished  like  the  rest  of  the  endocardium. 

Another  source  of  impediment  to  the  circulation  in  endocardi- 
tis is  the  formation  of  fibrinous  coagula  from  the  blood,  which 
are  supposed  to  contract  adhesions  to  the  lining  membrane  at  any 
accidentally  rough  or  prominent  point,  and  may  be  seen  twisting 


408  THORACIC    DISEASES. 

about  the  fleshy  columns,  and  valvular  tendons.  (Bouillaud.)  To 
these  Laennec  ascribed  the  origin  of  warty  vegetations.  Dr.  Ger- 
hard considers  them  more  frequently  the  cause  than  the  effect  of 
endocarditis,  and  ascribes  their  origin  to  that  fibrinous  condition  of 
the  blood  characteristic  of  inflammatory  disease. 

The  fibrinous-sub-serous  exudation  that  is  seen  in  sthenic  en- 
docarditis is  according  to  the  best  evidence  sometimes  changed  in- 
to a  fibrinous,  cartilaginous  or  bony  structure.  Such  a  deposition 
on  or  near  a  valve,  of  course,  causes  permanent  lesion. 

During  the  progress  of  endocarditis  the  muscular  structure  of 
the  heart  is  more  or  less  affected.  But  the  precise  extent  of  the 
cardiac  lesion  it  is  difficult  to  demonstrate.  According  to  Dr.  Ger- 
hard the  heart  increases  in  consistence,  and  becomes  harder  than 
usual  immediately  after  the  inflammation  of  the  membrane  has 
ended. 

DIAGNOSIS. —  General  symptoms. — The  general  symptoms  of 
endocarditis  are  very  obscure.  So  nearly  do  they  resemble  those 
of  pericarditis,  that  an  enumeration  of  them  cannot  be  of  much 
utility.  It  is  sufficient  to  say,  that  in  general,  they  are  not  vio- 
lent, and  that  in  a  large  number  of  cases  they  are  so  slight,  that 
the  disease  is  quite  latent.  In  the  severe  cases,  the  pain  may  be 
somewhat  acute,  but  even  then  it  is  dependent  upon  the  attend- 
ing pericarditis,  and  the  obstruction  to  the  free  circulation  of  the 
1}lood.  So  that  in  simple  endocarditis  pain  is  a  symptom  so  vari- 
able, that  it  cannot  be  depended  upon  for  the  formation  of  diag- 
nosis. Dyspnoea  is  another  symptom  upon  which  we  cannot 
with  confidence  rely.  It  is  often  violent,  causing  intense  suffer- 
ing, and  attended  with  signs  of  obstructed  capillary  circulation. 
In  such  cases,  the  patient  has  a  haggard,  wild  appearance. 

The  character  of  the  pulse  is  another  sign  of  endocarditis.  It 
is  tense,  though  small  and  irregular.  Very  great  irregularity  is 
indicative  of  a  severe  form  of  cardiac  disease,  and  is  usually  the 
result  of  lesions  of  the  valves.  These  three  symptoms,  the  pain, 
the  dyspnoea,  and  the  pulse,  are  the  most  important,  and  almost 
the  only  ones  which  are  generally  attendant  upon  inflammation  of 
the  endocardium.  Delirium  may  arise,  in  the  last  stage. 

Physical  signs. — Usually  the  impulse  of  the  heart  is  increased, 


ENDOCARDITIS.  409 

and  irregular  on  account  of  the  irritation  of  the  organ.  Dullness 
extends  over  a  larger  space  than  usual,  and  is  dependent  upon  an 
abnormal  accumulation  of  blood  in  the  cardiac  cavities.  "  This 
dullness  is  distinguished  from  that  of  pericarditis  by  the  sounds  of 
the  heart,  being  louder  and  less  distant,  by  the  impulse  appearing 
superficial  to  the  sight  and  touch,  and  synchronous  with  the  first 
sound  instead  of  fluctuating."  Respiration  too,  is  slightly  audible 
in  the  praecordial  region. 

Another  sign  is  the  bellows  murmur  either  with  the  first  or  sec- 
ond sound  of  the  heart.  Usually  it  is  heard  in  a  prolongation  of 
the  systolic  sound  ;  and  when  it  is  so  heard,  and  at  the  same 
time  there  are  symptoms  of  acute  inflammatory  disease,  pain  in 
the  prascordia,  frequent  pulse,  and  palpitation,  the  existence  of  en- 
docarditis is  clearly  characterized.  Still  more  evidence  of  its  ex- 
istence is  added  if  the  above  symptoms  just  alluded  to  occur  in 
an  individual  previously  healthy,  and  during  an  attack  of  acute 
"  rheumatism.  The  murmur  is  supposed  to  arise  from  partial  ob- 
struction or  defective  closure  of  the  orifices  of  the  valves. 

The  murmur  differs  much  in  its  degree  of  roughness.  Some- 
times it  is  soft  and  almost  musical,  sometimes  harsh  or  rough,  and 
sometimes  so  powerful  as  to  mask  the  ordinary  sounds. 

Endocarditis  seldom  exists  in  an  uncomplicated  form,  being 
mingled  with  pericarditis  or  myocarditis.  It  is,  therefore,  impos- 
sible to  find  many  cases  in  which  the  disease  is  wholly  confined 
to  the  endocardium. 

For  the  purpose  of  aiding  those  who  wish  to  cultivate  accuracy 
in  diagnosis,  I  give  the  distinctive  features  of  endocarditis.  First, 
then,  by  the  existence  of  the  bellows  murmur  we  suspect  the  ac- 
cession of  endocardial  inflammation.  By  the  position  of  the 
sound,  by  the  direction  in  which  it  is  heard,  by  the  time  of  its 
occurrence.  If  the  murmur  is  synchronous  with  the  systole  of 
the  heart,  as  before  stated  in  the  general  description  of  cardiac 
sounds,  it  must  accompany  the  egress  of  blood  from  the  heart,  and 
must  arise  either  from  an  obstruction  at  the  aortic  valves,  prevent- 
ing the  free  onward  flow  of  the  blood,  or  from  regurgitation 
through  the  mitral  valve.  But  if  it  is  coetaneous  with  the 
diastole  of  the  heart, — with  the  ingress  of  blood  into  the  ventri- 
cles,— then  it  must  be  caused  either  by  an  obstruction  in  the 
52 


410  THORACIC    DISEASES. 

mitral  valve,  or  by  regurgitation  through  the  aortic  outlet.  But 
how  can  we  discriminate  between  the  murmurs  produced  on  op- 
posite sides  of  the  heart  ?  or  how  refer  each  sound  to  its  proper 
valve  ?  These  questions  so  far  as  the  nature  of  the  subject  permits, 
I  have  already  answered  in  the  description  of  the  sounds  of  the 
heart.  Bat  a  brief  recapitulation  in  this  connection,  may  not  be 
amiss.  Obstruction  at  the  aortic  orifice,  is  marked  by  a  systolic 
murmur  heard  most  distinctly  at  its  base,  and  along  the  course  of 
the  aorta,  and  by  a  pulse  weak  at  the  wrist.  Disease  of  the  mitral 
valve  is  indicated  by  a  systolic  murmur  heard  towards  the  apex 
and  to  the  left  of  the  heart  more  distinctly  than  at  its  base,  by 
irregularity  in  the  pulse,  and  inequality  in  its  force  and  fullness. 

The  causes  of  endocarditis  are  very  similar  to  those  of  pericar- 
ditis. It  may  be  excited  by  injuries,  blows,  sudden  check  to  per- 
spiration and  by  mental  influences.  With  pneumonitis  and  pleu- 
ritis  it  sometimes  is  intimately  connected.  But  the  most  frequent 
of  all  its  causes,  is  acute  articular  rheumatism.  Some  have  sup- 
posed that  the  articular  affection  is  transferred  by  metastasis  to  the 
endocardium.  Of  the  truth  of  this  there  is  not  much  evidence. 
The  inflammation  of  the  endocardium  probably  depends  upon  the 
same  general  cause,  the  existence  of  too  much  acidity  and  fibrin 
in  the  blood,  that  produces  the  inflammation  of  the  joints.  Ac- 
cordingly we  often  see  the  cardiac  disease  precede  or  accompany 
the  rheumatic  affection  of  other  parts  of  the  system.  Mental 
emotion  and  irritability  may  predispose  the  heart  to  take  on  in- 
flammatory action,  and  thus  give  rise  to  the  development  of  endo- 
carditis even  before  any  general  rheumatic  affection  is  manifest. 
Under  such  circumstances  a  general  course  of  depuratory  treatment, 
a  course  whose  adoption  will  remove  the  acidity  and  the  cause  of 
that  acidity  from  the  blood,  is  indicated ;  and  the  idea  of  remov- 
ing that  condition  of  the  blood  by  venesection,  is  one  which  ap- 
pears to  me  utterly  destitute  of  reason  or  common  sense. 

PROGNOSIS. — The  acute  affection  under  a  good  course  of  treat- 
ment is  rarely  fatal,  and  it  progresses  to  a  termination  in  a  week, 
and  in  some  cases  in  less  than  that  period. 

In  violent  cases  death  sometimes  takes  place  in  a  few  days. 
The  cause  of  so  early  dissolution  has  been  attributed  to  the  for- 


ENDOCARDITIS.  411 

mation  of  coagula  in  the  cavities  of  the  heart.  Other  cases  al- 
though appearing  violent,  run  on  a  number  of  weeks  before  they 
arrive  at  an  unfavorable  termination. 

The  worst  result  of  endocarditis  is  the  chronic  alteration  of  the 
valves.  It  does  not,  however,  follow  that  cases  in  which  the  bel- 
lows murmur  remains,  after  the  subsidence  of  the  acute  symp- 
toms, will  necessarily  terminate  in  incurable  valvular  disease. 
The  exuded  lymph  is  absorbed,  and  the  impediment  to  the  flow 
of  blood  through  the  orifices  of  the  heart,  is  wholly  removed. 
When  it  is  otherwise,  the  valvular  derangement  leads  ultimately 
to  lesions  which  end  in  hypertrophy  and  dilatation.  The  general 
and  rational  symptoms  indicative  of  a  fatal  termination,  are  fre- 
quency and  irregularity  of  the  pulse,  violent  palpitations,  distress^ 
ing  dyspnosa,  and  syncope. 

TREATMENT. — The  treatment  of  endocarditis  is  almost  precisely 
the  same  as  that  of  pericarditis.  To  repeat  the  several  remedies 
which  were  recommended  in  the  chapter  on  pericarditis,  would 
be  unnecessary.  But  a  few  suggestions  relative  to  treatment,  may 
not  be  unimportant.  Endocarditis  involving  as  it  does  the  mem- 
brane reflected  on  the  inside  of  the  heart,  and  over  the  surface  of 
the  valves,  and  riot  being  liable  to  the  same  effects  from  the  prod- 
ucts of  inflammation,  should  be  vigorously  combatted  at  its  onset. 
For,  if  coagulable  lymph  is  to  a  great  extent  exuded  upon  the 
endocardial  surfaces,  it  will  render  the  deposition  of  fibrin  more 
probable,  and  thus  will  be  more  productive  of  permanent  organic 
lesion.  The  baths  and  diaphoretics,  and  the  other  means  to  re- 
move that  acid  and  fibrinous  condition  of  the  blood, — if  such  a 
condition  should  occur  as  the  effect  of  rheumatic  disease, — should 
be  perseveringly  applied.  It  is  best,  however,  not  to  administer 
very  large  quantities  of  medicine  ;  for  reaction  is  apt  to  be  excited, 
and  the  difficulty  increased.  It  is  better  to  give  small  but  fre- 
quent doses,  to  bring  down  the  arterial  excitement  gradually, 
rather  than  suddenly.  The  former  manner  of  administration  does 
not  so  much  exhaust  the  patient,  and  is  not  so  liable  to  cause  that 
depression  of  the  heart,  which  in  this  disease  is  always  injurious. 
When  the  cutaneous  heat  is  great,  alkaline  bathing  will  very  much 
aid  in  the  production  of  diaphoresis. 


412  THORACIC    DISEASES. 

Iii  cases  complicated  with  pneumonitis  and  pleuritis,  expector- 
ants combined  with  the  general  anti-inflammatory  remedies,  she uld 
be  given.  When  the  endocarditis  is  complicated  with  rheuma- 
tism,— and  such  is  the  fact  in  nearly  one-half  of  all  the  cases 
of  endocarditis, — the  remedies  for  rheumatism  should  be  used,  in 
conjunction  with  such  local  means  as  the  exigencies  of  the  case 
require.  If  the  inflammation  is  excessive,  attended  with  a  full 
tense  pulse,  give  the  extract  of  lobelia  in  frequent  and  increasing 
doses,  until  considerable  nausea  is  produced  ;  and  let  this  nausea 
be  kept  constant  during  several  hours.  After  the  nausea  subsides, 
in  order  to  secure  to  the  patient  rest,  a  small  quantity  of  extract 
of  lobelia, — not  enough  to  produce  sickness, — may  be  given  in 
combination  with  acetate  of  morphine.  .It  is  well  known  to  the 
eclectic  branch  of  the  medical  profession,  that  lobelia  contains  an 
alkaloid  principle,  which  without  doubt  makes  its  use  more  valu- 
able in  this  disease.  It  should,  however,  be  here  recollected,  that 
in  the  low  grades  of  inflammation,  in  asthenic  cases,  when  the 
muscular  fibre  of  the  heart  is  evidently  weakened,  the  action  of 
lobelia  or  of  any  other  powerful  relaxing  means,  is  contra-indica- 
ted. If  given  at  all  under  such  circumstances,  it  should  be  in 
combination  with  stimulants  in  small  proportions. 

Its  complication  with  pericarditis  with  pericardial  effusion, 
"should  be  treated  with  the  remedies  recommended  for  the  latter 
disease. 

In  the  treatment  of  cardiac  diseases,  certain  general  principles 
should  be  observed  as  guides  to  the  kind  of  treatment.  Every- 
thing which  tends  to  produce  an  equilibrium  in  the  circulation  of 
the  blood,  to  expel  from  it  those  abnormal  products  which,  arising 
sometimes  from  unknown  sources,  cause  cardiac  disease,  is  useful. 
AH  exciting  causes,  so  far  as  possible  should  be  removed,  and  qui- 
etness and  freedom  from  mental  anxiety  enjoined.  When  the  dis- 
ease assumes  a  sub  acute  and  chronic  form,  and  there  is  evidence 
that  the  valves  are  implicated  to  a  considerable  extent,  relaxants 
should  be  wholly  avoided,  and  a  mild  tonic  course  of  treatment 
instituted.  Some  alterative  sirup  given  three  times  per  day,  and 
the  use  of  the  lobelia  and  gall  pill  at  bed  time,  together  with  small 
doses  of  podophyllin  or  irisin  in  case  the  functions  of  the  liver 
are  not  properly  performed,  and  absorption  is  desired,  the  occa- 


MYOCARDITIS.  413 

sional  use  of  the  alcohol  and  vapor  bath,  not  continued  so  as  to 
excite  the  pulse,  these  are  the  means  most  effectual  in  arresting 
the  progress  of  the  disease,  or  of  postponing  its  fatal  termination. 
When  so  great  irritability  exists  that  the  use  of  narcotics  is  abso- 
lutely necessary,  and  when  at  the  same  time  there  is  general  de- 
bility, some  tendency  to  oadema  and  anosmia,  the  following  com- 
pound may  sometimes  alleviate  the  symptoms: — 

R          Extract!  conii  5  i., 

Ferri  carbonatis  3  ii. 

M.  ft.  pil.  xxx. 

Dose, — one  pill  two  or  three  times  per  day.  The  quantity 
should  be  gradually  increased  in  case  the  narcotic  effect  is  not  at 
first  produced. 


CHAPTER  IV. 

MYOCARDITIS. 

The  term  myocarditis,  from  the  Greek  ^s  muscle,  xap&a 
heart  and  itis,  is  an  inflammation  of  the  muscular  structure  of 
the  heart.  Of  this  variety  of  cardiac  disease,  our  knowledge  is 
very  limited ;  and  it  is  so  because  paralysis  of  muscular  fibre  ap- 
pears to  precede  its  disorganization.  Of  this  as  a  simple  uncom- 
plicated disease  we  k:io\v  nothing.  Extreme  pericarditis  some- 
times extends  to  the  muscular  structure,  and  endocarditis  likewise 
implicates  the  tissue  adjacent  to  its  own  locality. 

PATHOLOGY. — The  results  of  the  pathological  changes  in  myo- 
carditis, are*  first,  an  injected  state  of  the  cellular  structure  fol- 
lowed by  serous  or  sero-sanguinolent  infiltration,  and  diminished 
consistence  of  the  muscular  fibre.  Secondly,  a  lardaceous  trans- 
formation of  the  tissues,  giving  a  homogenous  appearance  to  the 
structures  ;  the  muscular  fibres,  however,  retaining  their  texture 
and  form.  Thirdly,  interstitial  suppuration  analogous  to  that  in 
the  advanced  stage  of  pneumonia.  Fourthly,  abscess  in  the  mus- 
cular structure  of  the  heart.  Fifthly,  superficial  ulcerations,  pre- 
senting a  cribriform  appearance.  These  maybe  seen  on  the  outer 


414 


THORACIC    DISEASES. 


surface  of  the  heart  in  connection  with  severe  pericarditis,  or  on 
the  inner  surface,  when  there  is  a  complication  with  intense  endo- 
carditis. 

* 

DIAGNOSIS. — We  have  no  means  of  diagnosticating  any  of  the 
forms  of  suppurative  myocarditis.  Of  other  organic  changes,  such 
as  rupture  of  the  valves,  the  occurrence  of  adherent  coagula,  pur- 
ulent cysts  in  the  heart,  and  partial  aneurism  of  the  ventricles,  we 
are  likewise  unable  to  form  a  diagnosis.  The  symptoms  of  car- 
ditis  or  myocarditis,  both  general  and  physical,  are  so  nearly  iden- 
tical with  those  of  other  varieties  of  cardiac  disease,  that  no  dis- 
crimination between  them  can  be  made. 

The  causes  are  the  same  as  those  of  other  forms  of  cardiac  dis- 
ease, and  the  treatment  adapted  to  their  removal,  is  equally  well 
calculated  to  remove  the  inflammation  of  the  muscular  tissue  of 
the  heart. 


CHAPTER    V. 

HYPERTROPHY. 

The  term  hypertrophy,  from  the  Greek  vifsp,  beyond,  and 
nourishment,  signifies  an  abnormal  degree  of  nutrition,  resulting 
in  augmentation  of  the  muscular  substance  of  the  heart.  Before 
the  year  1811,  this  affection  was  but  imperfectly  understood. 
Corvisart  had  recognized  under  the  name  active  aneurism,  the 
hypertrophy  with  dilatation  of  Laennec.  M.  Berlin,  in  1811,  re- 
vealed the  most  important  characteristics  of  this  disease.  Later 
pathologists,  have  added  perspicuity  to  its  nomenclature,  but  have 
for  the  most  part  confirmed  the  accuracy  of  his  observations. 

Of  hypertrophy  three  varieties  are  described. 

1.  Simple  Hypertrophy,  in  which  the  walls  are  thickened,  the 
cavity  retaining  its  natural  dimensions. 

2.  Hypertrophy  with  Dilatation. — This  is  the  eccentric  hyper- 
trophy of  authors,  in  which  the  muscular  parietes  are  thickened, 
and  the  corresponding  chamber  becomes  unnaturally  large. 

3.  Hypertrophy  with  Contraction. — "  It  has  been  supposed  that 
the  capacity  of  a  cavity  may  diminish  in  size  as  the  muscular  par- 


HYPERTROPHY.  415 

ietes  increase  in  thickness,  or  that  the  hypertrophy  takes  place  at 
the  expense  of  the  cavity." 

This  is  the  concentric  hypertrophy  of  authors. 

"  Of  these  three  forms  of  hypertrophy,  considered  in  their  rela- 
tion to  disease,  two  only,  the  simple  and  eccentric,  have  any  real 
existence.  The  third  or  concentric  form  never  occurs,  I  believe, 
except  as  a  congenital  malformation."  [Watson.] 

Cruveilhier  first  rejected  from  the  number  of  cardiac  diseases, 
concentric  hypertrophy.  The  physical  condition  which  received 
this  name,  he  regarded  as  transient,  and  dependent  upon  the  mode 
of  death.  In  the  bodies  of  those  decapitated  by  the  guillotine, 
the  heart  was  found  to  present  that  phenomenon  which  authors 
have  considered  an  actual  disease.  He,  therefore,  concluded  that 
the  physical  condition  named  by  many  pathologists,  concentric 
hypertrophy,  was  caused  by  death  suddenly  arresting  the  action 
of  an  hypertrophied  heart  "  in  all  its  energy  of  contractility." 

Sudden  death  from  hemorrhage,  by  which  the  heart  is  rapidly 
emptied  of  blood,  may  give  rise  to  the  appearance  of  this  variety 
of  hypertrophy,  by  allowing  the  muscular  tissue  to  contract  upon 
itself.  Not  unfrequently  it  happens,  that  a  diseased  heart  when 
first  removed  from  the  chest,  appears  enormous,  and.  that  after 
the  removal  of  the  blood  from  its  cavities,  it  contracts  upon  itself 
and  greatly  diminishes  in  size. 

In  the  left  ventricle  this  semblance  of  concentric  hypertrophy 
is  most  frequent,  and  is  most  often  present  soon  after  sudden 
death,  while  the  heart  is  contracted  by  the  rigor  mortis.  Some 
authors,  however,  differ  from  this.  The  above  cause  of  concen- 
tric hypertrophy,  according  to  Dr.  Wood,  cannot  well  apply  to  all 
cases;  "for"  he  remarks,  "contraction  has  often  been  observed 
in  cases  of  lingering  death,  and,  although  by  the  introduction  of 
the  finger  into  the  ventricles  the  muscular  spasm  may  in  many 
cases  be  overcome,  yet,  in  rare  cases  the  mechanical  dilatation 
may  be  the  result  of  expansibility  of  the  tissue,  rather  than  of 
muscular  relaxation." 

The  first  variety,  simple  hypertrophy,  is  not  frequent,  as  the 
cavities  are  usually  altered  in  size.  To  the  ventricles  it  is  confin- 
ed ;  for  dilatation  usually  attends  hypertrophy  of  the  auricles.  In 
this  variety  there  is  no  increase  in  the  bulk  of  the  heart. 


416  THORACIC    DISEASES. 

The  second  variety,  eccentric  hypertrophy,  is  the  most  frequent 
of  all  the  varieties  of  cardiac  enlargement.  Of  this  authors  speak 
of  two  forms, — one  attended  with  thickening,  the  other  destitute 
of  it.  As  the  cavities  are  distended,  it  is  obvious  that  in  the  lat- 
ter, as  well  as  in  the  former  case,  there  must  be  an  increase  in 
the  quantity  of  muscular  tissue,  and  consequently  a  real  hypertro- 
phy, unless  the  parietes  are  absolutely  attenuated.  Indeed,  some 
attenuation  might  exist,  and  the  quantity  of  muscle  still  be  greater 
than  in  health. 

PATHOLOGY. — j-The  degree  of  enlargement  varies  from  its  natura 
size  to  three  or  four  times  its  normal  volume.  Dr.  Clend inning 
found  the  average  weight  in  this  disease  15  ounces.  Its  shape 
becomes  more  globular,  its  cavities  much  enlarged,  its  position  ir 
the  chest  more  transverse,  its  fleshy  columns  are  stretched  and 
sometimes  thickened,  its  orifices  sometimes  expanded,  and  the 
valves  increased  in  size.  Its  muscular  fibre  becomes  harder  and 
more  resisting,  retaining  a  deep  red  color  when  other  tissues  are 
pale.  Hypertrophy  by  deranging  the  circulation  produces  lesions 
in  other  organs.j  The  liver  becomes  engorged  from  the  impedi- 
ment to  venous  circulation.  Its  acini  become  enlarged  and  its 
color  assumes  a  yellowish  tint,  and  decided  cirrhosis  follows. 
Jaundice  sometimes  supervenes  from  this  cause.  Similar  effects 
are  observed  in  the  kidneys.  The  cortical  substance  is  altered, 
and  granular  degeneration  is  produced. 

Causes. — Among  the  more  important  of  these  are  sudden  and 
severe  exercise,  mental  excitement,  rheumatism  exciting  endo- 
carditis, or  any  other  inflammatory  cardiac  affection,  valvular  ob- 
structions, or  dilatations. 

DIAGNOSIS. —  General  Symptoms. — The  additional  increase  in 
the  action  of  the  heart  gives  rise  to  an  increase  in  the  force  of 
the  circulation.  In  hypertrophy  of  the  left  ventricle  the  pulse 
becomes  strong,  full  and  hard,  the  impulse  of  the  heart  seeming 
like  the  stroke  of  a  hammer.  Very  frequently  the  arterial  circula- 
tion is  very  much  more  active  that)  normal ;  and  hence  occasional 
headache,  vertigo,  epistaxis.  Sometimes  in  severe  cases,  the  face 
is  flushed  or  of  a  purplish  hue,  the  features  swollen,  the  eyes 


HYPERTROPHY.  417 

prominent,  and  indicative  of  congestion.  Apoplexy  may  be  the 
result  of  the  arterial  congestion.  In  hypertrophy  of  the  right 
ventricle  the  symptoms  are  somewhat  different  from  the  anatomi- 
cal arrangement  of  the  vessels.  The  lungs  and  liver,  and  in  fact 
all  the  organs  immediately  connected  with  the  venous  circulation, 
are  then  more  suhject  to  congestion  and  hemorrhage.  Hypertro- 
phy with  but  little  dilatation  gives  rise  to  a  small,  tense  pulse.  In 
hypertrophy  caused  by  regurgitation,  the  cardiac  impulse  may  be 
great,  but  the  pulse  is  weak.  In  this  case  pulmonary  congestion 
is  more  liable  to  occur  in  consequence  of  the  impediment  to  the 
return  of  the  blood  from  the  lungs  to  the  heart,  and  arterial  conges- 
tion is  less  common  than  in  other  varieties.  Impediments  to  the 
circulation  of  the  blood  caused  by  contraction  at  the  valvular  ori- 
fices may  prevent  the  fullness  and  force  of  the  pulse.  In  some 
cases  the  degree  of  the  impediment  and  the  increase  in  the  cardiac 
pulsation  are  so  equally  balanced,  as  to  give  rise  to  no  marked 
disturbance  in  the  general  system.  Regurgitation  tends  to  reduce 
the  fullness  and  force  of  the  pulse,  so  that  the  cardiac  impulse 
may  be  strong,  and  perhaps  excessive  and  yet  the  radial  pulse  not 
be  correspondingly  changed  in  its  character.  Disease  of  the 
valves  usually  causes  more  irregularity  of  the  pulse  than  occurs 
from  other  causes. 

From  reason  we  should  conclude  that  hypertrophy  of  the  right 
side  of  the  heart  would  cause  similar  effects  in  the  venous  system, 
that  the  same  affection  of  the  left  side  causes  in  the  arterial.  But 
this  is  not  corroborated  by  facts ;  and  imperfect  closure  in  the  tri- 
cuspid  valves  permitting  regurgitation  is  supposed  to  be  the  cause. 
The  symptoms  of  hypertrophy  of  the  right  ventricle  are  pulsation 
of  the  jugulars,  headache  and  vertigo,  a  pale,  dusky  hue  of  the 
face,  and  a  purplish  appearance  of  the  lips.  Dr.  Wood  mentions, 
as  a  very  characteristic  symptom,  a  double  pulsation  of  the  jugu- 
lars, corresponding  in  strength  and  interval  to  the  cardiac  contrac- 
tions. 

Physical  Signs. — In  simple  hypertrophy  there  are  three  promi- 
nent symptoms,  the  increase  of  impulsion,  the  dullness  of  percus- 
sion and  the  alteration  in  the  cardiac  sounds.  The  impulsion  is 
almost  always  much  increased,  seeming  to  give  a  kind  of  heaving 
motion  to  the  prascordia.  Its  extent  is  also  increased,  and  more 
53 


418  THORACIC    DISEASES. 

particularly  so  when  hypertrophy  is  combined  with  dilatation. 
The  impulsion  is  very  different  from  that  caused  by  nervous  irri- 
tability ;  that  produced  by  the  latter  cause  being  sharp  and  quick, 
that  by  the  former  more  like  the  increasing  pressure  of  a  large 
mass  against  the  ribs.  In  every  kind  of  hypertrophy  this  is  a 
very  characteristic  symptom. 

Percussion  is  much  changed  by  this  disease.  The  enlargement 
of  the  heart  makes  the  dullness  perceptible  over  a  much  larger 
space  than  normal,  and,  consequently  as  the  enlargement  is  little 
or  great  so  is  the  extent  of  the  flatness  on  percussion  small  or 
great.  In  the  eccentric  hypertrophy  it  is  more  extended.  Some- 
times amounting  over  the  centre  of  the  prsecordia  to  perfect  flat- 
ness. 

The  cardiac  sounds  become  abnormal.  In  general  the  second 
sound  is  less  sharp,  the  first  more  or  less  prolonged,  verging  on  to 
the  bellows  murmur.  In  complication  with  dilatation,  the  loud- 
ness  and  sharpness  of  the  sounds  may  remain,  the  dilatation  com- 
pensating for  the  deadening  effect  of  hypertrophy  on  the  cardiac 
sounds.  Sometimes  there  is  a  prolonged  bellows  murmur.  These 
physical  signs,  together  with  the  evidences  furnished  by  the  gen- 
eral symptoms,  will  generally  make  a  diagnosis  sure.  The  in- 
creased impulse,  variation  in  the  cardiac  sounds,  dullness  on  per- 
cussion, and  the  dyspnoea,  dropsy,  palpitation,  will  be  sufficiently 
characteristic  of  the  nature  of  the  cardiac  lesion.  To  distinguish 
between  hypertrophy  of  the  right  and  left  ventricle  is  not  always 
easy.  The  symptoms  of  the  former  are  venous  congestion  of 
the  head,  pulsating  jugulars,  absence  of  arterial  excitement. 
Those  of  the  latter  are  already  described. 

PROGNOSIS. — When  dependent  upon  organic  changes  in  the 
valves  there  is  little  or  no  hope  of  a  cure.  In  the  young  there  is 
much  more  than  in  the  aged.  Usually  its  progress  is  slow — ad- 
vancing step  by  step  to  a  fatal  termination,  either  suddenly  from 
some  casual  excitement  to  the  circulation,  or  slowly  from  exhaust- 
ion and  dropsical  effusions. 

General  Treatment  of  Organic  Diseases  of  the  Heart. — It  is 
customary  for  medical  writers  to  discuss  the  treatment  of  each  of 
the  cardiac  affections  separately.  To  this,  the  objection  may  well 


HYPERTROPHY.  419 

be  urged,  that  disease  is  seldom  presented  in  an  isolated  form,  that 
in  many  cases  changes,  not  only  in  the  mechanical,  but  in  the  vital 
state  of  the  organ,  are  continually  going  on ;  and  that  even  with 
the  existence  of  organic  disease,  the  state  of  the  blood,  and  of 
the  general  system  has  a  potent  influence  upon  the  physical  signs, 
and  on  the  results  of  medication.  Nor  should  it  be  forgotten  that 
the  symptoms  of  the  original  organic  lesion  are  often  rendered  ob- 
scure by  the  great  constitutional,  or  local  disturbance,  that  secon- 
darily arises.  Mindful  of  this  caution  the  practitioner  should  look 
back  of  the  mere  phenomena,  to  that  cause,  whether  general  or 
local,  which  is  the  source  of  the  symptoms. 

Tf  the  cause  be  general,  as  in  anosmia,  or  if  it  be  disease  of 
some  other  organ,  which  by  sympathy  has  caused  an  abnormal 
condition  of  the  heart,  and  if,  after  that  continued  symptomatic 
action  of  the  heart  has  resulted  in  actual  lesion,  the  same  remote 
causes  still  continue  in  operation,  then,  reason  would  direct  rem- 
edial agents  to  the  removal  of  the  remote  cause,  and  at  the  same 
time  would  seek  to  allay  the  violence  of  distressing  symptoms  ; 
for  the  mechanical  condition  of  the  various  parts  of  the  heart, 
is  only  one  object,  whose  knowledge  should  at  all  guide  in  the 
prescription  of  medicine.  And,  therefore,  to  lay  down  treatment 
which  must  be  changed  with  every  pathological  change  in  the 
heart,  is  not  only  useless, — because  it  far  transcends  human  ability 
to  tell  every  one  of  those  changes, — but  it  is  also  of  no  practical 
importance.  Diseases  of  the  heart  are  in  general  a  series  of 
pathological  changes,  arising  at  first  from  some  general  cause,  and 
often  made  continuous  by  the  continual  action  of  causes,  similar 
to  those  which,  at  first,  produced  the  lesions. 

A  knowledge  of  the  vital,  rather  than  of  the  mechanical  con- 
dition should  be  the  guide  in  practice.  A  full  acquaintance  with 
the  various  effects,  remote  as  well  as  immediate  of  disease  of  the 
heart,  and  of  its  functional  derangements,  will  enable  the  practi- 
tioner to  avoid  those  egregious  blunders  in  the  treatment  of  car- 
diac affections,  which  so  often  disgrace  the  profession. 

The  tendency  of  pathological  science  is  to  engross  too  much 
of  that  attention  which  should  be  paid  to  the  treatment  of  disease. 
With  many  physicians  the  failure  is  not  so  much  in  the  amount 
of  learning  which  they  possess,  as  in  the  application  of  that 


420 


THOKACIC    DISEASES. 


knowledge  to  some  practical  purpose.  The  physician  who  would 
be  successful  in  the  treatment  of  cardiac  disease,  must  bear  in  re- 
membrance the  ascertained  facts  of  pathological  science,  and 
found  his  diagnosis,  prognosis,  and  treatment  on  a  basis  that  in- 
cludes all  the  effects,  causes,  and  modifications  of  the  disease. 
This  is  an  important  desideratum  ;  for  the  phenomena  of  cardiac 
disease  are  ever  varying,  so  that  the  vital  condition  cannot  always 
be  determined  by  the  external  signs. 

In  view  of  these  considerations  a  guiding  principle  of  treatment 
becomes  very  necessary  in  diseases  of  the  heart.  Heretofore,  car- 
diac diseases  even  in  their  chronic  form,  have  been  treated  by 
active  depletion,  by  frequent  venesection.  Such  was  the  treat- 
ment of  Laennec,  and  now  the  same  or  a  similar  course  is  recom- 
mended by  Bouillaud  and  Albertini,  and  Valsalva. 

More  modern  authors,  however,  condemn,  or  very  rarely  recom- 
mend the  use  of  the  lancet.  Dr.  Latham  says  :  "  The  indisposi- 
tion to  use  the  lancet  in  chronic  diseases,  and  in  the  vast  number 
of  acute  affections,  is  one  of  the  best  evidences  we  can  have  of  a 
safe  and  scientific  practitioner."  Drs.  Stokes,  and  Hope,  and 
Pennock,  rarely  recommend  this  remedy. 

It  may  then,  I  think,  safely  be  considered  as  a  general  rule, — 
and  in  this  remark  I  utter  the  sentiment  of  Professor  Newton, — 
that,  in  cardiac  diseases,  especially  those  of  an  organic  nature,  no 
antiphlogistics  should  be  used,  which  tend  merely  to  palliate  for 
the  time,  but  which  secondarily  so  depress  vitality,  so  impoverish 
the  blood  and  derange  the  equilibrium  of  its  circulation,  as  in  the 
end  to  do  an  actual  injury.  Sedative  and  diaphoretic  agents,  the 
use  of  frictions,  of  the  warm  bath,  to  determine  to  the  surface, 
are  much  safer,  and  at  the  same  time  more  efficient  in  the  end, 
than  a  decided  depleting  course. 

In  general  the  insufficiency  of  the  valves,  a  consequent  regur- 
gitation  or  a  contraction  of  the  valvular  orifices,  produce  either 
simple  hypertrophy,  or  hypertrophy  with  dilatation.  Why  these 
effects?  Simply  because  an  additional  amount  of  labor  is  thrown 
upon  the  muscular  texture  of  the  heart  in  consequence  of  the 
failure  of  the  valves  to  perform  their  normal  action.  In  such 
cases  nature,  to  enable  the  heart  to  perform  the  additional  labor 
increases  its  muscular  fibre, — produces  what  is  called  hypertrophy, 


HYPERTROPHY.  421 

in  accordance  with  the  general  law,  that  the  greater  the  labor 
within  certain  limits,  imposed  upon  a  muscle,  the  thicker  and 
stronger  it  becomes.  If  the  thickening  of  the  muscles  of  the 
blacksmith's  arm  in  consequence  of  active  exercise,  is  a  healthy 
or  normal  process,  I  ask,  where  is  the  consistency  of  calling  a 
hypertrophied  heart,  a  diseased  one  ?  or  of  using  depletion  in  any 
form  whatever  to  break  down  those  necessary  fortifications  against 
the  approach  of  death,  which  nature  constructs? 

When  the  valves  are  diseased,  and  their  functions  either  par- 
tially or  wholly  destroyed,  how  can  a  heart  of  normal  muscular 
strength,  produce  that  circulation  on  which  life  depends? 

The  greater  the  impediment,  the' greater  should  be  the  force  to 
overcome ;  and  on  this  principle,  nature  acts ;  while  too  often  the 
physician  is  ignorantly  seeking,  in  every  possible  manner,  to  di- 
minish that  hypertrophy,  without  which,  so  long  as  the  valvular 
obstructions  remain,  life  could  not  exist.  In  fact,  I  honestly  be- 
lieve that  the  bleedings,  starvings,  the  enforcement  of  debilitating 
measures,  which  formerly  were  commonly  enjoined,  have  tended 
to  counteract  the  efforts  of  nature,  and,  consequently,  have  been 
the  cause  of  immense  mischief  to  mankind. 

Instead  of  this  course  of  treatment,  the  means  employed  should 
be  such  as  tend  to  strengthen  the  general  constitution,  to  give 
vigor  to  the  muscular  tissue  of  the  heart,  and  thus  to  enable  it  to 
carry  -on  its  normal  functions  in  opposition  to  existing  obstruc- 
tions. 

A  generous  diet  of  animal  and  vegetable  food  may,  therefore, 
be  allowed.  But  the  use  of  such  beverages  as  tend  to  increase 
the  mass  of  fluids,  but  not  their  nutritive  properties,  should  be 
prohibited.  The  fear  of  sudden  death,  or  any  other  depressing 
mental  influence,  tends  to  injure  the  patient,  and  hence,  the  ne- 
cessity of  its  removal  so  far  as  this  can  be  effected. 

Treatment  of  Hypertrophy. — The  treatment  of  this  disease 
may  be  considered  under  the  two  general  heads,— curative,  and 
palliative.  That  simple  hypertrophy,  not  dependent  upon  organic 
lesion  is  curable,  admits  of  no  doubt.  But  unfortunately,  such 
cases  are  rare,  while  those  dependent  upon  organic  disease,  are  by 
far  the  most  numerous.  Curative  treatment  is  not,  therefore,  ap- 
plicable to  a  great  many  cases,  but  the  palliative  is  necessary  in 


THORACIC    DISEASES. 

the  majority.  This,  however,  should  be  combined  with  curative 
treatment,  and,  indeed,  in  many  cases  this  is  the  most  judicious 
course  of  medication. 

The  art  of  treating  hypertrophy  with  a  curative  object  in  view, 
consists  in  keeping  the  circulation  tranquil,  in  preventing  plethora 
by  abstinence  from  too  stimulating  diet,  and  yet  by  avoiding  the 
use  of  those  means  which  tend  to  produce  anasmia,  debility,  and 
their  immediate  effects.  When  this  desirable  state  can  be  obtained, 
without  the  production  of  debility,  the  heart,  like  any  other  hy- 
pertrophied  muscle,  possesses  a  surprising  power  of  reverting  to  its 
normal  size.  The  suspension  of  its  over  exertion  by  such  a  course 
of  treatment,  affords  for  the  organ  the  most  favorable  condition  of 
cure. 

Remedies  may  aid  somewhat  in  the  attainment  of  the  same 
object.  Whenever  the  capillary  circulation  is  feeble,  the  extrem- 
ities cold, — a  condition  seldom  observed  in  simple  hypertrophy, — 
frictions  to  the  surface,  the  use  of  the  bath,  and  the  administra- 
tion of  permanent  stimulants,  in  combination  with  diaphoretics, 
will  be  the  most  sure  to  remove  the  Cardiac  derangement. 

The  particular  remedies  which  I  would  recommend,  are  capsi- 
cum, lobelia,  lupulin  and  asafoetida.  These  combined  according 
to  the  exigencies  of  the  case,  will  be  as  serviceable  as  any  with 
which  I  am  acquainted.  In  case  the  beating  of  the  heart  is  ex- 
cessive, and  there  is  evidence  of  plethora,  the  lobelia,  and  ner- 
vines should  be  increased  in  quantity,  and  the  stimulant  lessened. 
In  cases  of  the  latter  kind,  such  as  are  attended  with  arterial  con- 
gestions, arising  from  the  increased  momentum  of  the  blood,  con- 
sequent upon  the  powerful  contraction  of  the  hypertrophied  heart, 
relaxants,  among  which  lobelia  is  the  most  efficient,  should  be 
given.  The  food  should  then  be  somewhat  reduced  in  quantity, 
and  strong  meats  abandoned.  Tea  and  coffee,  particularly  the  lat- 
ter, are  inadmissable,  and  all  causes  of  excitement,  whether  men- 
tal or  physical,  should  be  removed. 

For  a  general  remedy,  in  cases  of  feeble  capillary  action,  to 
equalize  the  circulation,  and  regulate  the  action  of  the  heart,  the 
following  pills  may  be  used : — 


DISEASE    OF    THE    VALVES    OF    THE    HEART. 


431 


Dose, — gr.  i.,  togr.  iii.,  as  occasion  requires.  Enough  should  be 
given  to  produce  a  laxative  effect.  In  connection  with  this  some 
alterative  sirup  may  often  be  taken  with  advantage.  The  cardiac 
symptoms  are  usually  in  the  inverse  ratio  to  the  feebleness  of  the 
capillary  circulation.  Means,  b9th  hygienic  and  remedial,  should, 
therefore,  be  used  in  order  to  prevent  the  congestion  of  blood  to 
the  internal  organs.  Warm  clothing,  nourishing,  but  easily  diges- 
tible food,  the  occasional  use  of  a  warm  bath,  not  long  continued  ; 
in  short  of  all  the  revulsive  means — are  the  principal  things  upon 
which  dependence  should  be  placed.  A  life  free  from  excitement 
of  every  kind  should  be  led  by  those  afflicted  with  chronic  cardiac 
disease.  When  the  palpitation  is  severe  and  the  dyspnoea  is  great, 
complete  repose  should  be  enjoined.  Sinapisms  may  be  applied 
to  the  chest,  and  pcdiluvia  to  the  feet.  Vegetable  diaphoretic 
compounds  may  often  be  used  with  benefit,  in  connection  with 
asafoetida  and  scutellaria. 

In  some  forms  of  heart  disease,  the  kalmia  latifolia  proves  effi- 
cacious. Dr.  A.  Bottom  has  used  a  saturated  tincture  in  doses  of 
ten  to  fifteen  drops,  or  in  quantities  sufficiently  large  to  slightly 
affect  the  sensorial  functions,  with  decided  benefit.  The  proba- 
bility is  that  the  remedy  has  the  best  effect  in  those  cases  in  which 
the  organic  lesions  are  slight,  and  the  distressing  symptoms  pro- 
ceed mostly  from  functional  derangement.  A  more  full  trial  of 
the  remedy,  may  reveal  its  utility  as  a  curative  agent. 

Counter  irritation  to  the  chest  and  upper  part  of  the  spinal 
column  is  sometimes  beneficial.  Various  other  remedies  may  be 
used,  but  the  guiding  principle  in  their  prescription  should  be  to 
prevent  the  progress  of  the  cardiac  changes  by  directing  means  to 
the  removal  of  all  exciting  causes,  and  to  place  the  system  in  that 
condition  most  favorable  to  the  prevention  of  the  ill  effects  arising 

i.  O 

from  the  cardiac  lesions. 

There  are  several  other  organic  affections  of  the  heart  which 
require  a  brief  notice.  Among  these  is  alrnpky,  which  during  life 
can  seldom  be  recognized  by  any  symptoms  to  which  it  gives  rise. 
Pressure,  adhesion,  deficient  nutrition  are  its  most  common  causes. 
General  treatment  is  usually  best  adapted  to  prevent  its  progress, 
and  hence  sueu  agents  should  be  ut-cd  as  tend  to  produce  cousli- 


432  THORACIC    DISEASES. 

tutional  vigor.  Another  affection  of  the  heart  is  softening.  This 
is  not  very  uncommon.  It  changes  the  appearance  of  the  heart, 
causing  a  pale,  purplish,  or  yellowish  color  of  its  texture  and  a 
great  degree  of  softness  of  its  muscular  fibre.  It  is  often  compli- 
cated with  obesity  and  fatty  degeneration.  It  arises  from  deficient 
nutrition,  from  venous  congestion,  and  sometimes  from  obstruc- 
tion in  the  coronary  vessels.  Dr.  Wm.  Pepper  lound  it  to  ac- 
company the  prostration  caused  by  sun  stroke.  The  general 
symptoms  are  a  small,  feeble  intermittent  pulse,  feeble  cardiac  im- 
pulse, and  syncope.  The  treatment  should  consist  of  tonics  and 
stimulants,  wine  whey,  carbonate  of  ammonia,  capsicum,  combin- 
ed with  nourishing  and  digestible  diet.  Induration  of  the  heart 
•sometimes  occurs;  likewise  ossification,  cartilaginous  and  calcare- 
ous deposits. 

Fatty  deposition  is  sometimes  observed  around,  and  within  the 
textures  of  the  heart.  There  are  two  forms  of  this  affection  ; 
first,  that  in  which  the  fat  envelopes  the  heart,  pushing  the  mus- 
cular fibre  before  it ;  and,  secondly,  that  in  which  the  degenera- 
tion commences  in  the  muscular  tissue,  transforming  the  muscular 
fasciculi.  These  two  forms  are  probably  produced  by  similar 
causes,  and  are  nearly  identical  in  their  nature.  It  gives  to  the 
heart  a  greasy  feeling. 

Its  symptoms  are,  feeble,  slow  pulse,  syncope,  neuralgic  pains 
in  the  chest,  dyspnoea  and  coma.  The  arcus  senilis,  a  fatty  de- 
generation of  the  cornea  of  old  people,  is  usually  accompanied 
with  a  similar  affection  of  the  heart.  The  impulse  and  first  sound 
of  the  heart  is  feeble.  Tubercles,  cysts,  hydatids,  and  partial  an^ 
eurisms  are  sometimes  observed  in  this  organ.  Polypus  and  con- 
cretions of  coagulated  fibrin  are  usually  found  in  the  right  cavities. 

The  Treatment  should  consist  of  mild  laxatives,  and  tonics, 
and  the  most  permanent  stimulants,  combined  with  nourishing 
diet.  There  is  little  danger  of  using  too  large  a  dose  of  pure 
stimulants.  Brandy  even  may  be  borne  in  larger  quantities  than 
in  most  any  other  disease. 


HYDROPERICARDIUM. 

CHAPTER    VIII. 

H  Y  D  11  0  P  E  R  I  C  A  11  D  I  U  M. 


433 


This  term  from  the  Greek  v5up  water,  ^spi  around,  and  xapoia 
heart,  is  applied  to  dropsy  of  the  pericardium.  In  health  there  is  a 
small  quantity  of  serum  in  that  cavity,  and  hence  Corvisart  consid- 
ered six  or  seven  ounces  necessary  in  order  to  constitute  disease. 
It  usually  accompanies  dropsy  of  other  parts  of  the  body.  Its  most 
characteristic  symptoms  are  a  small,  feeble,  irregular  pulse,  lividity 
of  the  face  and  lips,  difficulty  of  dorsal  decubitus,  and  dyspnoea. 
A  variable  position  of  the  cardiac  impulse  has  been  considered  as 
a  characteristic  symptom.  The  physical  signs  are  dullness  over 
a  large  surface,  prominence  of  the  praecordia,  diminution  of  the  respi- 
ratory murmur.  When  dependent  upon  inflammation  or  upon  a 
general  dropsical  diathesis  it  is  sometimes  curable,  —  but  when 
upon  organic  disease  of  the  heart,  there  is  little  or  no  hope.  The 
treatment  should  be  similar  to  that  recommended  for  hydrothorax. 


CHAPTER  IX. 

FUNCTIONAL   DISEASES    OF    THE    HEART. 

Symptomatic  affections  of  the  heart  are  more  common  than 
organic,  often  exciting  unnecessary  alarm.  Functional  cardiac 
diseases  assume  various  forms,  at  one  time  so  distinct  as  to  be 
easily  recognized,  at  another  presenting  such  a  group  of  symptoms 
as  to  make  the  diagnosis  extremely  difficult.  The  term  nervous 
is  applied  to  several  different  conditions  of  the  heart.  Among 
these  is  palpitation.  Oftentimes  this  is  most  excessive,  and 
arises  from  disorder  of  the  digestive  organs,  from  uterine  sympa- 
thy, or  from  excitement  caused  by  excesses  of  any  kind  whatever. 
The  free  use  of  tea,  and  more  especially  of  coffee  and  tobacco,  is 
a  very  frequent  cause.  Violent  exercise  will  often  produce  palpi- 
tation. Anosmia  existing  while  tobocco  is  freely  used,  tends  in 
a  great  degree  to  aggravate  the  palpitation,  and  to  develop  the 


434 


THORACIC    DISEASES. 


bellows  murmur.  But  this  nervous  palpitation  is  not  so  constant, 
nor  so  permanent  as  that  arising  from  organic  lesion.  Its  access 
is  more  sudden,  and  is  more  often  the  effect  of  some  excitement. 
Whenever,  therefore,  the  physician  is  making  an  examination 
upon  which  a  diagnosis  is  to  be  based,  the  habits  of  the  patient, 
his  temperament,  his  liability  to  excitement  should  be  considered. 
To  the  free  use  of  tobacco  and  coffee,  I  have  often  traced  the 
cause  of  palpitations  which  were  supposed,  both  by  patients  and 
even  by  some  physicians,  to  have  arisen  from  organic  disease. 
Dr.  Hope  remarks,  that  one  half  of  the  patients  who  presented 
themselves  to  him  with  the  idea  that  they  were  suffering  from 
disease  of  the  heart,  were  suffering  from  nothing  more  \ha\\  func- 
tional disturbance  of  that  organ.  It  is,  therefore,  necessary  in 
the  formation  of  a  correct  diagnosis,  to  recollect  that  the  character 
of  organic  disease  is  to  progress,  that  of  functional  to  occur  at 
irregular  intervals,  that  active  exercise  almost  always  aggravates 
organic,  but  seldom  increases  the  symptoms  of  the  functional ;  that 
the  physical  signs,  generally,  are  soon  developed,  and  remain  per- 
manent in  the  organic,  while  they  seldom  exist — and  when  they 
do,  they  result  from  anaemia  or  chlorosis, — in  the  functional,  that 
the  organic  cannot  generally  be  traced  very  directly  to  exciting 
causes,  while  the  functional  often  arises  from  venereal  excesses, 
masturbation,  and  those  other  influences  already  mentioned. 

Pain  in  the  heart  is  often  a  nervous  affection.  When  very 
acute,  it  is  more  often  of  a  nervous  character  than  a  symptom 
arising  from  organic  djsease.  Sometimes  it  is  sharp,  lancinating, 
extending  from  the  heart  to  the  spine,  and  wandering  in  its  char- 
acter. A  general  soreness  sometimes  extends  over  the  pracordia 
and  the  integument  of  the  chest. 

Intermittence  of  the  pulse  is  very  common.  In  some  this  is 
almost  congenital,  continuing  through  a  series  of  years  without 
inducing  organic  disease.  Its  intensity  greatly  varies  at  different 
times,  and  under  different  circumstances.  This  symptom,  like  the 
former,  is  an  attendant  upon  both  organic  and  functional  derange- 
ments, and,  therefore,  is  not  a  sure  guide  in  diagnosis. 

ANGINA  PECTORIS. — This  has  been  considered  a  disease  of  a 
neuralgic  character,  and  as  separate  from  all  others.  It  is  sup- 


AORTITIS. 


435 


posed  to  have  its  origin  both  in  functional  and  in  organic  disease. 
The  symptoms  are  extreme  pain  extending  down  the  arms,  usu- 
ally the  left,  great  dyspnoea,  occurring  suddenly  arid  produced  by 
some  excitement.  Ordinarily  the  attack  soon  passes  off  leaving 
the  patient  comparatively  well,  after  the  endurance  of  intense 
suffering. 

The  treatment  should  be  of  a  stimulating  character;  pediluvia, 
sinapisms  to  the  praecordia  may  be  applied,  and  the  tincture  of 
capsicum  and  lobelia  combined  with  some  anodyne  should  be 
given  internally.  Between  the  attacks,  mild  stimulants  should  be 
used  in  order  to  produce  an  equilibrium  in  the  circulation  of  the 
blood.  The  compound  lobelia  pills,  with  a  small  proportion  of 
lobelia,  will  have  a  very  good  effect. 

For  palpitation  arising  from  anasmia,  ferruginous  tonics  should 
be  used,  combined  with  stimulants,  arid  nourishing  diet.  All  ex- 
citing causes  should  be  removed.  Nervines  are  also  useful,  and 
in  extreme  cases,  narcotics.  The  state  of  the  stomach  should  re- 
ceive especial  attention,  and  emetics  be  given  when  indicated. 


DIVISION  III. 

AORTIC  DISEASES. 
CHAPTER  I. 

AORTITIS. 

Inflammation  of  the  aorta  has  the  same  characteristics  that  en- 
docarditis presents;  and  all  the  difference  there  is  between  them, 
is  in  their  location.  Some  authors,  therefore,  do  not  treat  of  this 
disease  under  a  separate  head. 

PATHOLOGY. — The  morbid  changes  are  the  same  as  those  of  en- 
docarditis, with  very  slight  modifications.  The  increased  veloci- 
ty of  the  blood  through  the  aorta,  tends  to  prevent  the  adhesion  of 
lymph  to  the  lining  membrane.  Sometimes  little  ulcers,  thick- 
ening, cartilaginous  deposits,  softening  of  tissues  are  seen  in  dif- 
ferent parts  of  the  diseased  membrane. 


436  THOKACIC    DISEASES. 

DIAGNOSIS. — This  is  very  obscure ;  the  disease  being  but  an 
extension  of  endocarditis,  the  distinctive  symptoms  are  very  few. 
The  impulse  of  the  aorta  is  sometimes  perceptible  over  the  course 
of  the  vessel.  The  physical  signs  are  increased  impulsion,  a  saw- 
ing or  double  rasping  sound  heard  at  the  upper  part  of  the  ster- 
num, one  part  of  the  sound  being  synchronous  with  the  onward 
flow  of  the  blood,  the  other  with  its  reflux.  The  treatment  of 
endocarditis  is  applicable  to  aortitis,  and,  therefore,  no  separate  de- 
scription of  the  remedies  is  necessary. 


CHAPTER    II. 

ANEURISM    OF    THE    AORTA. 

Aneurism  from  the  Greek  avsupjvw,  is  an  enlargement  of  a  part  or 
the  whole  of  the  circumference  of  an  artery.  They  are  divided 
into  several  varieties,  a  full  description  of  which  is  unnecessary. 
Aneurism  of  the  thoracic  portion  of  the  aorta  comes  within  the 
limits  of  this  work. 

PATHOLOGY. — The  various  morbid  changes  arising  from  inflam- 
mation, such  as  depositions  of  lymph,  softening  cartilaginous  de- 
posits, are  the  usual  antecedents  of  aneurism.  It  is  usually  an 
effect  of  these  several  changes,  and,  therefore,  its  pathology  can- 
not differ  from  that  given  in  endocarditis  and  aortitis,  except  in  its 
being  a  more  remote  sequence  of  a  continued  train  of  pathologi- 
cal changes.  The  early  changes  weaken  the  aortic  parietes,  and 
consequently  their  dilatation  follows.  This  dilatation  of  course 
takes  place  at  the  weakest  points,  sometimes  producing  a  little 
pouch.  The  inner  coat  of  the  artery  ulcerates,  and  the  blood 
presses  upon  its  cellular  stricture,  dilating  it,  and  thus  producing 
the  aneurism.  The  whole  artery  may  dilate,  or  some  one  portion 
of  it.  They  may  be  caused  by  a  sudden  strain.  According  to 
Bizot  they  occur  most  frequently  upon  the  posterior  surface  of  the 
aorta,  the  proportion  being  as  103  to  27.  Out  of  87  cases  of  tho- 
racic aneurism,  40  were  located  in  the  ascending,  31  in  the  arch, 
and  16  in  the  descending  aorta.  They  vary  much  in  size, — some- 
times becoming  so  large  as  to  press  upon  contiguous  viscera. 


ANEURISM    OF    THE    AORTA.  437 

They  cause  death  in  two  ways ;  first,  by  pressure  upon  adjacent 
organs;  secondly,  by  the  rupture  of  their  parietes.  Their  pres- 
sure upon  a  nerve  causes  paralysis,  upon  a  bone,  caries,  or  its  ab- 
sorption. 

DIAGNOSIS. — The  signs  are  a  pulsation  felt  over  the  course  of 
the  aorta,  sometimes  a  thrilling  sensation,  the  sawing  sound,  dull- 
ness on  percussion.  But  these  are  seldom  present  in  all  cases. 
Among  the  general  symptoms  are  a  thrilling  pulse,  and  neuralgic 
pain  in  the  'chest.  It  was  the  assertion  of  Laennec,  that  there  is 
no  sign  pathognomonic  of  thoracic  aneurism  except  the  external 
tumor,  and  its  truth  is  now  acknowledged  by  many  pathologists. 

In  many  instances  a  tolerable  degree  of  accuracy  may  be  ar- 
rived at,  but  there  is  no  certainty  of  the  existence  of  the  aneu- 
rism unless  the  sac  pushes  out  the  parietes  of  the  chest.  Two 
aneurismal  sacs  are  never  exactly  alike,  and  consequently  the 
sounds  proceeding  from  them  must  be  subject  to  so  great  varia- 
tion as  to  make  a  diagnosis  uncertain  when  based  upon  them. 
When  aneurism  is  suspected,  the  patient  should  be  interrogated  in 
respect  to  his  occupation,  previous  habits,  the  occurrence  of  blows, 
falls,  or  violence  of  any  kind,  the  interrogator  remembering  that 
small  aneurisms  may  exist  a  long  time  without  producing  incon- 
venience. 

The  blood  vessels  of  the  arm.  and  the  veins  of  the  neck  should 
be  examined.  The  palms  of  the  hands  may  then  be  passed  over 
both  sides  of  the  chest,  for  the  purpose  of  detecting  an  abnormal 
impulse  and  protrusion  of  the  thoracic  walls.  If,  on  a  thorough 
physical  exploration,  "  an  abnormal  bruit  is  detected,  the  effect 
of  position  and  motion  should  be  tried,  and  the  question  asked, 
whether  the  bruit  may  not  arise  from  valvular,  or  other  disease  of 
the  heart,  from  a  roughened  state  of  the  arterial  tube,  or  whether 
a  tumor — probably  malignant — may  not  by  interfering  with  the 
current  of  blood,  occasion  it.  (Edema  of  the  hand,  pain  in  the 
arms  and  fingers,  the  condition  of  the  voice,  the  appearance  of  the 
countenance,  the  character  of  the  pain,  state  of  breathing,  haemop- 
tysis, previous  diseases,  and  hereditary  predisposition  of  the  pa- 
tient, are  all  important  subjects  of  investigation.  Proper  attention 
paid  to  the  above  rules,  will  generally  enable  the  physician  to 


438  THORACIC    DISEASES. 

form  a  correct  diagnosis;  but  it  is  easier  to  say  that  this  disease 
is  not  present  than  to  foretell  its  existence  No  sounds  are  path- 
ognomonic  of  thoracic  aneurism.  Double  sounds,  single  sounds, 
in  all  varieties  from  the  grating  noise  of  the  saw,  to  the  murmur  of 
the  gentle  breeze  may  be  heard,  and  yet  not  denote  anetirismal 
dilatation."  [Rank.  Abs.  No.  17.  1853,  p.  80.] 

PROGNOSIS. — The  disease  may  be  considered  as  incurable  by 
medicine,  although  aneurism  may  exist  during  many  years,  and 
not  terminate  in  death.  Such  cases,  however,  occur  among  those 
of  a  quiet,  placid  turn  of  mind,  and  among  such  as  are  not  sub- 
ject to  excitement. 

TREATMENT. — In  the  discussion  of  the  treatment  best  adapted 
to  the  alleviation  of  the  distressing  symptoms  of  aneurism,  noth- 
ing more  than  palliative  means  needs  to  be  considered.  On  the  one 
hand,  efforts  should  be  used  to  retard  the  progress  of  the  disease, 
on  the  other  to  diminish  the  suffering  arising  from  it.  Such 
means  in  rny  opinion,  as  materially  interfere  with  the  condition  of 
the  general  system,  tending  in  any  way  whatever  to  debilitate  or 
to  excite  the  nervous  system,  are  not  admissible.  It  often  hap- 
pens that  a  patient  who  has  not  been  the  subject  of  medical  treat- 
ment, will  continue  with  unimpaired  health  until  he  is  so  unfor- 
tunate as  to  begin  to  use  active  means  for  the  cure  of  aneurism. 
The  patient's  mind  then  becomes  apprehensive  ;  his  system  is 
weakened ;  his  digestive  system  injured  by  starvation.  The  re- 
sult is  an  impoverished  state  of  the  blood  ;  in  it  there  is  but  little 
fibrin,  and  consequently  it  becomes  uncoagulable,  and  the  tissues 
of  the  vessels  unresisting.  This  want  of  fibrin  deprives  nature  of 
the  instrument  upon  which  she  relies  for  the  repair  of  the  injury ; 
for  the  formation  of  coagula  in  an  aneurismal  sac  is  a  curative 
process  which  should  not  be  prevented.  By  depleting  agents,  the 
force  of  the  aneurismal  throb  is  augmented,  and  a  disease  which 
under  favorable  circumstances  might  have  continued  for  years, 
suddenly  terminates  in  death.  The  means  most  effectual  for  re- 
tarding the  progress  of  the  disease,  are  freedom  from  all  excite- 
ment, a  nutritious  and  generous  diet,  the  use  of  some  mild  stim- 
ulant, capsicum,  or  a  moderate  quantity  of  wine.  Dr.  Stokes  re- 


ANEURISM    OF    THE    AORTA.  439 

lates  a  case  of  large  aneurism  with  weak  heart,  which  illustrates 
the  effect  of  a  generous  regimen.  "  The  patient,  after  a  six  weeks' 
course  of  very  low  living,  became  almost  desperate  from  the  in- 
tensity of  the  pains,  the  loss  of  sleep,  and  the  violence  of  the 
throbbings.  While  passing  through  a  city,  the  thought  entered 
his  mind  that  he  would  have  one  good  dinner  before  he  died.  On 
entering  a  tavern  he  ordered  a  sumptuous  repast  of  turtle-soup, 
fish,  roast-meat,  and  wild-fowl.  Of  these  he  partook  freely.  He 
drank  a  bottle  of  Madeira,  and  two  glasses  of  brandy  punch ;  and 
declared  to  me  that  when  he  rose  from  the  table,  he  felt  perfectly 
relieved  from  all  his  sufferings.  He  slept  well  that  night,  and 
continued  so  free  from  distress  of  any  kind  for  many  days,  that 
he  thought  himself  cured  of  his  terrible  disease."  Such  a  course, 
however,  would  not  be  safe  for  all  cases.  Sudden  changes  in 
diet  are  not  so  well  borne,  as  more  gradual  ones.  In  case  inflam- 
matory symptoms  arise  in  those  afflicted  with  aneurism,  the  anti- 
inflammatory  agents  should  be  used  for  the  purpose  of  palliating 
the  symptoms  ;  but  caution  should  be  used  in  the  prescription  of 
any  active  evaciient  remedies.  Perfect  quiet,  the  use  of  some  re- 
laxant and  sedative  agent,  will  arrest  the  inflammation ;  and  then 
other  means  such  as  tend  to  improve  the  condition  of  the  blood 
and  the  general  system  may  be  used. 

To  diminish  the  suffering  arising  from  aneurism,  various  exter- 
nal applications  to  the  surface  may  be  made,  and  the  internal  use 
of  some  sedative,  is  sometimes  admissible.  Among  the  external 
applications  to  the  diseased  part,  the  most  efficient  are  chloroform, 
cold  water  or  ice,  an  irritating  plaster  over  the  spine  in  case  the 
location  of  the  aneurism  is  near  the  vertebras,  or  a  plaster  of  bel- 
ladonna, in  case  the  tumor  is  painful  or  requires  support.  Among 
the  nervine  and  sedative  agents,  are  lobelia,  lupulin  and  the  ex- 
tract of  indian  hemp.  This  latter  article  has  been  used  with  suc- 
cess in  many  cases  of  nervous  diseases ;  and  on  account  of  this  I 
would  suggest  to  the  profession  the  propriety  of  making  a  more 
full  trial  of  its  virtues  as  a  sedative  agent. 


APPENDIX    OF    FORMULA. 


DR.  NEWTON'S  COMPOUND  SIRUP  OF  SANGUINARIA  AND 

LOBELIA. 

R  Sirupi  simplicis  Oii. ;  tincturae  lobeliae  |  v. ;  tincturas  san- 
guinariae  §  v.  ;  spirit!  anisi  5iii. ;  tinctures  gaultheriae  5  iss. 
Misce. 

Dose — one  teaspoon ful  as  often  as  indicated. 

DR.  NEWTON'S*  COMPOUND  NERVINE  TINCTURE. 

R  Sic.  Mad.  vini.  Oii. ;  pulveris  cypripedii  §  iv. ;  pulveris 
scutellariae  §  iv.  ; 

Dose — one  dram  once  in  four  hours. 

DR.  NEWTON'S  DIAPHORETIC  POWDER. 

R  Myricae,  zinziberis,  populi  a  a  §  iv. ;  capsici  3  ii. ;  asclepia- 
dis  §  i.  Misce. 

Dose — one  teaspoonful  once  in  four  hours. 

DR.  NEWTON'S   ANTI-FEBRILE  POWDER. 

R     Asclepiadis,  ictodis,  lobelias  a  a  §  i.     Misce. 

Dose — from  one  half  to  a  teaspoonful  once  in  four  hours. 

COMPOUND  LOBELIA  PILLS. 

R  Lobelias  sem.  pulveris,  capsici,  pulveris  a  a  §  .  :  sodas  bicar- 
bonatis  3  ii. ;  acacias  pulveris  3ii.  Misce.  ft.  gr.  iv.  pill. 

3213     1   I 


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UNIVERSITY  of  CALIFORNIA 

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293     Newton- 
F48t     Thoracic 
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3  1158  00128  7191 


A    001410661    1 


